14 Nursing Leadership through Informatics

Facilitating and Empowering Health Using Digital Technology

Shauna Davies

Twitter is not a technology, it’s a conversation—and it’s happening with or without you.

—Charlene Li (2014)

Introduction

Information plays a vital role in the nursing process. As nurses, we collect information about our clients, use this data to develop nursing care plans, implement the plan, and communicate our findings with other health care providers. Advances in information technology allow nurses and nursing students to access vital information with the click of a button. For example, in hospitals and clinic offices, health care providers have access to electronic health records, which provide access to private and confidential client health information in a secured environment. Services such as telehealth provide a means for client education, as well as medical and health care services such as health monitoring or clinical diagnosis. Social media is also being used in health care to provide a means for clients to share experiences with one another or learn more about their medical condition.

Now more than ever, nurses have the opportunity to communicate and plan care more effectively, in collaboration with clients and other health care providers, due to advances in technology. This chapter will provide you with a deeper understanding of nursing informatics and technology. Additionally, the nurse’s role in relation to electronic health records, telehealth, telehomecare, and social media will be discussed.

 

Learning Objectives

  1. Define the terms nursing informatics, e–Health, and m–Health.
  2. Develop an understanding of the risks and benefits of using electronic health records.
  3. Develop an appreciation for standardized terminologies.
  4. Develop an understanding of telehealth and telehomecare.
  5. Differentiate between telehealth and telehomecare.
  6. Develop an understanding of various web 2.0 tools used in health care.
  7. Discuss the role of nurses in developing clients’ health literacy.
  8. Describe the necessary steps to ensure privacy and security of personal health information.

14.1 Health Informatics

Nursing Informatics

Health information systems specialize in storing, managing, capturing, and transmitting information about the health of individuals along with all activities within the health care organization (CASN, 2012). Nursing informatics is a specialty that incorporates nursing care with the use of computers and information science to provide information about nursing care delivery. The Canadian Association of Schools of Nursing (CASN) developed a resource that outlines the competencies required by nursing students upon graduation (see CASN, 2012). When entering the workforce, graduate nurses are expected to (1) use information to support safe, effective, and evidenced-informed care for their clients; (2) follow workplace, professional association, and regulatory bodies’ standards with respect to information and communication technologies; and (3) be able to use information and communication technologies in practice. Required skills include, but are not limited to, searching for credible and reliable health information online and assisting clients and their families in finding and evaluating the credibility and reliability of online health information.

 

From the Field

Understanding principles related to nursing informatics is important for student nurses who will both observe and experience countless examples of clients’ use of technology throughout their careers. Examples include:

  • working in a rural setting and using telehealth for a client’s appointment with a specialist;
  • using electronic health records in daily practice; and
  • using a medical app to assist in delivering safe, effective client care.

e-Health

e-Health is a term used by Health Canada to describe the information and communication technologies used in health care, which includes a range of services such as electronic patient administration systems, lab and diagnostic tests, information services, and telehealth and telehomecare monitoring devices (including remote vital sign monitoring).

m-Health

Mobile technology has changed the way health care providers communicate, monitor, and connect with clients, families, and other health care providers. Any mobile device with smartphone capabilities allows for downloading apps, which are self-contained computer programs that run directly on the device’s home screen. This m-Health technology includes many different types of medical- and health-related apps, currently available either free of charge or for a fee.

Health and fitness apps are generally intended for daily individual use and are related to monitoring or informing about a variety of healthy activities such as calorie counting or exercise (Aungst, Clauson, Misra, Lewis, & Husain, 2014; Martinez-Pérez, de la Torre-Diez, & López-Coronado, 2013). Medical apps focus more on health care practices and may assist in communication or pictorial representation of a medical condition or may help to record blood pressure or blood sugars in clients with hypertension or diabetes.

The use of m-Health technology may have potential security issues. Many health apps currently available require the client to input personal health information (Cummings, Borycki, & Roehrer, 2013). The developer informs the user of the terms of use (including use of personal health information) by requiring a confirmation agreement before the app can be used. If the client agrees to the terms of use, users must be informed of who has access to any personal information placed within the app. Clients also need to be informed if this information will be monitored by their health care provider or if someone else outside the circle of care will have access to this health information, such as the app developer. All health care providers must follow HIPA (Health Information Protection Act) when using apps with multiple clients so that any personal information is de-identified. If more than one client is accessing a mobile device during a hospital stay or health consult, it is also important to develop privacy policies to prevent clients from accessing another client’s health information entered into the app.

Infection control procedures must be developed based on the type of devices in use within the health care setting. Health care providers must consider infection control procedures when devices are shared between clients.

When choosing health care apps for clients, providers must consider factors such as the client’s age, the cost of the app, and app-specific features (e.g., email, messaging, or support groups) to determine if they will meet the needs of the client (Ristau, Yang, & White, 2013). If the client is to use the app upon discharge or at home, it must be cost effective. Some apps require an internet connection, so the client will need to have regular or intermittent access to the internet. The app must also be easy to use and updated regularly to provide current, reliable information.

 

Essential Learning Activity 14.1.1

For more information on nursing informatics, see CASN’s report titled “Nursing Informatics: Entry-to-Practice Competencies For Registered Nurses,” then answer the following questions:

  1. What three entry-to-practice informatics competencies does CASN set out?
  2. Select one of these competencies and list the indicators.

For more information on privacy, review the sites below, then answer the questions that follow:

Health Insurance Portability and Accountability Act for Professionals, US Department of Health and Human Services

  1. Can health information be shared in a severe disaster?
  2. Who has the right to consent with respect to whether a covered entity may electronically exchange a minor’s protected health information to or through a health information organization?

Your Personal Health Information and Privacy (Government of Saskatchewan)

  1. Who are the trustees under the Health Information Protection Act?
  2. What rights do you have with respect to your personal information?

How do I get access to information? (Office of the Saskatchewan Information and Privacy Commissioner)

  1. How do you access the type of information you need from the Office of the Saskatchewan Information and Privacy Commissioner?

14.2 Risks and Benefits of Electronic Health Records

Electronic Health Records

Electronic health records systems are used in various hospitals, community health settings, and doctor’s offices to enter and view client information. Unique client identifiers are used to ensure that information about the client is linked with the correct health care provider, the client’s most recent results of laboratory and diagnostic tests, and an updated list of currently prescribed medications. Information about the client’s vaccination history, allergies, consults, operative reports, and discharge information is also provided. A benefit of using electronic health records is that health care providers have quick access to medical information. Clients benefit as they receive improved management of chronic diseases, such as when health care professionals can receive reminders of follow-up tests. Electronic health records also reduce unnecessary repetition of laboratory and diagnostic testing, which ultimately saves money. A risk of electronic health records is that people not within the circle of care may access confidential information. Regional health authorities have taken measures to monitor for such risks. These measures include providing limited access and monitoring who is viewing any confidential health information.

Electronic health records may also include the use of standardized evidenced-based protocols for nursing care. Nurses can access the most current evidenced-based protocol to see potential nursing interventions, which can serve to improve documentation of assessments and interventions by providing reminders to chart specific symptoms or to chart the administration of PRN medications.

Standardized Terminologies

Overview

Electronic health systems use standardized clinical terminologies so that all health care providers can communicate findings and share client information within their specific practice settings. Standardized clinical terminologies refer to a set of common terms that describe health conditions, treatment plans, and necessary interventions. Two examples of commonly used standardized clinical terminologies include the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) and Canadian Health Outcomes for Better Information and Care (C-HOBIC). Standardized clinical terminologies facilitate the measuring and recording of nursing care and data in a way that can be understood by other health care providers. Monitoring the length of time it takes to perform a nursing procedure is an example of recorded data that can then be used to help organize care. This recorded data can also be used to describe specific nursing activities, and their impact on client outcomes, including the client’s progression toward discharge.

Benefits of Standardized Clinical Terminologies for Nursing

Nursing practice guidelines, developed by the Registered Nurses’ Association of Ontario, are based on the results of systematic reviews, an expert panel, and stakeholder review. These nursing practice guidelines can be embedded electronically into any nursing plan of care to reduce variation in care based on a specific medical condition. By using a common terminology and following a specific plan of action, researchers will be more effective in using the information and comparing results with other information globally. These nursing interventions can then be described and understood by other health care providers as the client transitions from the hospital to community or home setting.

 

From the Field

It is important to maintain client confidentiality and follow the policies of workplace and regulatory bodies when using information and communication technologies.

 

Essential Learning Activity 14.2.1

Read Canada Health Infoway’s webpage about Electronic Health Records, then answer the following questions:

  1. Explain why digital records need to be available to all authorized health care providers.
  2. What are the challenges to and solutions for providing a comprehensive framework for sharing health information across the country?
  3. The 2016 Digital Health Blueprint identified ten computing environments. What are they?
  4. When determining how to implement a particular digital health solution, designers have many decisions to make. List three of these decisions.

14.3 Telehealth and Telehomecare

Telehealth is an information and communication technology that allows for health services to be delivered over a distance using electronic or telecommunication devices. The benefit of using telehealth technology is that health care is accessible to all persons no matter where they reside. For example, the client may access this service in their community instead of travelling to see a specialist in a larger community. A nurse is available to the client throughout the appointment and provides care to the patient in various forms such as assessment or education. The nurse may perform a physical assessment and relay the results to the physician using telehealth technology. The nurse–client relationship continues as the nurse becomes involved with any education and support of the client throughout the assessment, planning, implementation, and evaluation stages. All care is documented according to agency protocol. Client safety is an important consideration throughout each interaction. Nurses working with the client must follow standards and competencies of the professional association in the province in which they are located, regardless of where the client is situated. If the client is receiving long distance care, extra consideration and high level assessment skills are required as the nurse does not directly perform the physical assessment on the client. Thus, there is an increased safety risk related to incomplete assessments. Following agency protocol, privacy, and confidentiality are maintained throughout the nurse–patient interface.

Telehomecare is similar to telehealth. The difference between telehomecare and telehealth is that telehomecare refers to services provided to clients in their own homes. Clients receive devices and training to monitor their own vital signs at home. These vital signs are relayed to a health care provider through a phone line or the internet. Health care providers watch for trends in the data to alert the physician or nurse practitioner about the need for follow-up. The main benefit of telehomecare is that clients and caregivers are provided with additional supports, which lead to a greater sense of independence, fewer emergency department visits, and reduced flare-ups.

 

Essential Learning Activity 14.3.1

  1. How can telehomecare help you care for your patients?
  2. How can telehomecare assist family caregivers in caring for family with COPD or heart failure?

14.4 Social Networking

Types

Social networking refers to any web-based or mobile platform that allow users to create and share conversations or content with other users or the public. Many types of social networking tools, such as Facebook and Twitter, focus on communicating with an established group of people, often those who are already known to each other. Another form of social networking, LinkedIn, helps to expand professional contacts as users make new connections online. Other popular social networking tools, such as YouTube, allow users to upload videos for public viewing. Each of these tools is presently being used in health care to: (1) connect clients with other clients dealing with the same health condition, (2) connect health care providers with other health care providers, or (3) connect health care providers with clients and families. For example, health care providers can use Twitter to monitor epidemics (e.g., searches can be performed to monitor tweets about influenza). YouTube can be used to educate clients about diet or even help them prepare for a surgery. These are only a few examples of how social networking can benefit client care.

Privacy Concerns

It is important to consider the legal and ethical obstacles—along with any associated risks and responsibilities—of incorporating social media into nursing practice. Social networking technology must be used appropriately, respectfully, and safely. Registered nurses must reflect on the CNA’s Code of Ethics for Registered Nurses (2017) which states that registered nurses must “safeguard the privacy and confidentiality of persons and other colleagues” (p. 21). Nurses must be aware of any applicable federal and provincial legislation such as the right to privacy and confidentiality of personal and health information (Sewell, 2016). In Saskatchewan, the Health Information Protection Act (HIPA) discusses the protection of electronic health information (Government of Saskatchewan, 2003).

Significant breaches of confidentiality have occurred when nurses posted comments, pictures, or videos that contain sufficient detail to identify a patient. Health care providers need to realize that posting anonymously or under a pseudonym does not protect the user against a breach of confidentiality or defamation of character (CNPS, 2012). Furthermore, nurses need to respect professional boundaries when becoming a “friend” or communicating health information, which may lead to personal liability if the nurse identifies him or herself as a nurse.

 

Research Note

Davies, S. (2016). Online Social Support in the Saskatchewan Heart Failure Network: An Interpretative Description Approach (Doctoral dissertation). University of Saskatchewan: Saskatoon.

Abstract

The management and prevention of cardiovascular disease is a significant challenge to the health care system, both nationally and internationally. Web-based tools are used by many health care professionals and health care organizations to communicate with patients, to collaborate with other health professionals, and to provide health information. This interpretive description research study explored the factors that have influenced and will continue to influence or contribute to caregivers’ use of social networking as a form of social support when a family member is learning to live well with heart failure. The researcher created, designed, and developed a social networking site for caregivers. Following focus group sessions with health care professionals, the Living Well with Heart Failure NING site was reviewed and approved for use. Six caregivers participated on the website and were interviewed before and after participation.

The results of this research study have implications for regional health authorities, health care professionals, and caregivers of patients living with heart failure. Health care professionals are encouraged to provide caregivers and patients with a variety of teaching materials both in print and electronically. Health care professionals should be encouraged to participate in web-based forums to share their experiences and learn from other health care professionals, caregivers, and patients living with heart failure. Such experiences can help new graduate nurses learn from more experienced nurses as regional health authorities can develop networks related to specific areas of practice. This will have many benefits as health care professionals can share medical research with each other as well as caregivers and patients.

Summary

Information technology has advanced the delivery of health care services. There are many benefits, including quick access to up-to-date medical information, accessibility for clients who may otherwise have to travel long distances to meet with a specialist, and availability of information 24 hours a day, 7 days a week at the click of a button. Nurses must consider legal and ethical challenges related to the use of technology in health care in order to provide safe, efficient, and effective care to all clients either virtually or in person.

After completing this chapter, you should now be able to:

  1. Define the terms nursing informatics, e–Health, and m–Health.
  2. Identify the risks and benefits of using electronic health records.
  3. Recognize the need for standardized terminologies.
  4. Verbalize the role and importance of telehealth and telehomecare.
  5. Differentiate between telehealth and telehomecare.
  6. Recognize and understand the various web 2.0 tools used in health care.
  7. Discuss the role of nurses in developing clients’ health literacy.
  8. Describe the necessary steps to ensure privacy and security of personal health information.

 

Exercises

  1. Review your current social media presence then describe the risks and benefits of using social media in a professional setting. Reflect on what you found. Now consider any risks and benefits related to your nursing image and professionalism.
  2. Review the Health on the Net (HON) code principles for medical and health websites. Find three websites that relate to your area of clinical interest. Would you recommend these websites to your clients? Why or why not?
  3. Reflect on a situation where a member of a health care team was reprimanded for posting information on social media. How will you ensure that you are maintaining confidentiality using social media?
  4. Review HIPA, HIPAA, and FOIP guidelines. How do you ensure that you are maintaining health information confidentiality in the clinical setting? What steps are taken by a health care organization to ensure confidentiality of health information? What information can a client request to see before, during, or after receiving medical care? What steps must be taken by the client to receive their personal health information?

References

Aungst, T. D., Clauson, K. A., Misra, S., Lewis, T. L., & Husain, I. (2014). How to identify, assess and utilise mobile medical applications in clinical practice. International Journal of Clinical Practice, 68(2), 155–162. doi:10.1111/ijcp.12375

Canada Health Infoway. (2018). Why electronic health records? Retrieved from: https://www.infoway-inforoute.ca/en/component/edocman/resources/videos/2267-why-electronic-health-records

Canadian Association of Schools of Nursing [CASN]. (2012). Nursing Informatics: Entry-to-practice competencies for registered nurses. Retrieved from: http://www.casn.ca/wp-content/uploads/2014/12/Nursing-Informatics-Entry-to-Practice-Competencies-for-RNs_updated-June-4-2015.pdf

Canadian Health Outcomes for Better Information and Care Project. (n.d.). Inclusion of nursing-related patient outcomes in electronic health records. Retrieved from: https://c-hobic.cna-aiic.ca/about/default_e.aspx

Canadian Nurses Association [CNA]. (2017). Code of ethics for registered nurses [2017 edition]. Retrieved from: https://www.cna-aiic.ca/html/en/Code-of-Ethics-2017-Edition/index.html#1/z

Canadian Nurses Protective Society [CNPS]. (2012). infoLAW: Social media, 19(3). Retrieved from http://www.cnps.ca/upload-files/pdf_english/social_media.pdf

Cummings, E., Borycki, E. M., & Roehrer, E. (2013). Issues and considerations for healthcare consumers using mobile applications. Enabling Health and Healthcare through ICT, 227–231. doi:10.3233/978-1-61499-203-5-227

Government of Alberta. (2017). Guidelines and Practices: 2009 Edition. Retrieved from: https://www.servicealberta.ca/foip/resources/guidelines-and-practices.cfm

Government of Saskatchewan. (2003). The Health Information Protection Act quick reference sheet. Retrieved from http://www.health.gov.sk.ca/hipa-quick-reference

Government of Saskatchewan. (n.d.). Your personal health information and privacy. Retrieved from: https://www.saskatchewan.ca/residents/health/accessing-health-care-services/your-personal-health-information-and-privacy

Health on the Net Foundation. (2017). The commitment to reliable health and medical information on the internet. Retrieved from: https://www.hon.ch/HONcode/Pro/Visitor/visitor.html

Li, C. (April 15, 2014). Twitter. Retrieved from: https://twitter.com/charleneli?lang=en

Martinez-Pérez, B., de la Torre-Diez, I., & López-Coronado, M. (2013). Mobile health applications for the most prevalent conditions by the world health organization: Review and analysis. Journal of Medical Internet Research, 15(6), e120.

Ristau, R. A., Yang, J., & White, J. R. (2013). Evaluation and evolution of diabetes mobile applications key factors for health care professionals seeking to guide patients. Diabetes Spectrum, 26(4), 211–214.

Sewell, J. (2016). Informatics and nursing: Opportunities and challenges. Philadelphia PA: Wolters Kluwer.

SNOMED International. (n.d.). SNOMED CT: The global language of healthcare. Retrieved from: https://www.snomed.org/snomed-ct

US Department of Health & Human Services. (n.d.). Health Information Privacy. Retrieved from: https://www.hhs.gov/hipaa/index.html

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Leadership and Influencing Change in Nursing Copyright © 2018 by Joan Wagner is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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