In April 2004, the president of the United States
issued an executive order that called for action
to put EHRs in place for most Americans in 10
Today there is growing consensus that EHRs, can
meet clinical and business needs in healthcare
by capturing, storing, and displaying clinical
information when and where it is needed to
improve treatment and to provide aggregated
cross-pattern data analysis.
These systems can manage healthcare data
and information in a way that is patient-centered
The involvement of nurses is critical to
such efforts responsible for care
coordination and promotion of wellness,
nurses are often the patient’s primary
contact and the final point in healthcare
delivery where medical errors and other
unintended actions can be caught and
After a brief overview and discussion of
the definition of EHR-Ss, this chapter
covers two main areas :
1. Federal initiatives and ;
2. Public-private partnership.
An early adopter of EHR-s the U.S
government is currently advancing
initiatives to accelerate the use of HIT in
both the public and private sectors.
Both sectors have done considerable EHR-S
innovation and some notable benchmark
implementation over the past decade
federal initiatives continue to actively
identify and target solutions that lessen the
barriers and accelerate use of EHR-S.
Improved information access and
availability can enable both the provider
and the patient to better manage the
patient’s health by using capabilities
provided by enhanced clinical decision
support and customized education
Nurses are drivers in organizational
planning and process reengineering to
improve the healthcare delivery system.
The term EHR-S is often used interchangeably
with computerized patient record, clinically
information system, electronic medical
record, and many others.
As a term EHR-S is recognized internationally by
including the word system, the term forces a
distinction between an EHR, which is physical or
logical(virtual) repository of data, and EHR-
S, which can be made up of one or more
At the time of writing, international organization
for the standardization (ISO) had drafted its
standard for EHR definition, escape, and
context, ISO 20514; the final version was
expected in 2005 or 2006.
EHR may be used by all participants in
the process of achieving
health, including all disciplines of
clinicians, family caregivers, and the
EHR-S provides the components that
support clinical and healthcare functions
including business rules, procedures and
so forth by accessing the EHR to write
and/or read patient data.
The set of components that form the
mechanism by which patient records are
created, used, stored and retrieved. A
patient record system is usually located
within a healthcare provider setting. It
includes people, data, rules and
procedures, processing and storage
devices and communication and
1. Longitudinal collection of electronic health
information for and about persons, where
health information is defined as information
pertaining to the health of an individual or
healthcare provided to an individual.
2. Immediate electronic access to person and
population level information by authorized,
and only authorized, users.
3. Provision of knowledge and decision support
that enhances the quality, safety, and
efficiency of patient care.
4. Support of efficient processes for healthcare
Within the federal government, different
departments exert different influences
toward the common goal of an EHR for
most Americans. Agencies providing direct
healthcare offer evidences that the use of
EHRS across a multifacility enterprise is a
realistic goal with measurable, repeatable
positive outcomes. Other agencies provide
leadership by offering monetary incentives
and shaping regulations and policy.
Federal Agencies that provide direct
care have been early adopters of EHRS.
Those that don’t are providing multiple
approaches to promote use of EHRS.
These include decreasing the cost and
risk of acquisition and providing
incentives for their use.
Government as Provider and early Adopter
-Federeal agencies that provide direct
care have been early adopters of EHR-s
Department of Veterans Affairs(VA)
-Veterans Information System and
TechnologyArchitecture(VistA) supports day
to day clinical and administrative
operations at local VA healthcare facilities
Department of Defense
-Have had a computerized physician
Indian health service
-The EHR-S as long had been pioneer
in using computer technology to
capture clinical and public health data.
Its primary clinical component, the
patient care component (PCC) has
been in place since the early 1980’s.
Government as Leader
-Federal agencies that do not provide
direct care are taking multiple
approaches to promote use of EHR-S.
-Federal activities are focus on the
development and adoption of
terminologies and standards, Grants for
community demonstrations of data
exchange and other pilot projects.
Office of the national coordinator for health
-The executive of April 2004, mentioned earlier
in the chapter, created the ONCHIT to coordinate
HIT efforts in the federal sector and collaborate
with the private sector in the driving HIT adoption
across the health care system.
- In July 2004, HHS secretary Tommy Thompson
and Dr.Brailer release a framework for strategic
action. The office of the national coordinator is
positioned to bring together a public and private
entity for accelerating solutions to known
The national committee on vital and
-In 2000 and 2001, the national
committee on vital and health statistics
(NCVHS), which advices the secretary of
HHS on health information policy, held a
series of national hearings to develop a
consensus vision of the national health
information infrastructure (NHII).
Agency for healthcare Research and
-In 2003-2004, AHRQ unveiled a major
HIT portfolio, with grants, contracts and
other activities to demonstrate the role
of HIT in improving patient safety band
the quality of care.
Computerized Patient Record System
CPRS (Computerized Patient Record
System) provided a single place for
healthcare providers to review and
update a patient’s health record.
All aspects of a patient’s record are
integrated including active problems,
allergies, and current medications. All
electronic records are password
protected to guarantee patient privacy.
A number of collaborative efforts are
focused on use of EHR-s and HIT to improve
Among these private sector organizations
are those formed specifically to address
issues of connectivity, HIT, and standards
development. Others are established
standards development organization; some
are based in professional association where
they arose in efforts to serve their
Institute of Medicine
-As an independent advisor to the
nation with the goal of improving health,
the IOM has championed the
advantages of IT to improve health since
its 1991 foundational work the computer
base patient record, which was revised
and republished in 1997.
Health Level Seven
- An intentional, not for profit, volunteer
standards, organization, health level seven
is known for its large body of work in the
production of technical specification for
the transfer of health care data.
- Supported by public and private groups
the HL7’s EHR technical committee
developed draft standard for trial
use, known as a DSTU, for EHRS and made it
available for public comment prior to being
reballoted as a standard.
Over the next 10 years, as the nation
moves toward the goal of EHRS, nurse
informaticists will have increased
opportunities to participate in the
activities of formative groups, using the
growing body of tools available to them.
This time of great change brings grand
opportunities for nursing informaticists
and the entire nursing profession.
The healthcare industry is undergoing a
dramatic transformation from today’s
inefficient, costly, manually, intensive,
crises-driven model of care delivery to a
more efficient, consumer-centric,
science-based model that proactively
focuses on health management.
The electronic health record (EHR) will form the
foundation for pervasive, personalized, and science-
The technologies that enable the transformation are
largely state of the art and include enterprise
application integration (EAI);wireless communications;
handheld and tablet computers; continuous speech
recognition; new models for knowledge
representation, integration, and interpretation;
electronic sensor; radio frequency identification (RFID)
tagging; and robotics.
The International Council of Nurses (ICN) Code
of Ethics for Nurses affirms that the nurse “holds
in confidence personal information” and
“ensures that use of technology is compatible
with the safety, dignity and rights of people.”
Fulfilling these ethical obligations is the
individual responsibility of the nurse, who
presumably has the ability and authority to
ensure that personal information is protected
and that technology is safe.
Thus, ethical obligations drive requirements for
Thus ethical obligations drive
requirements for Dependability, which
comprises 6 attributes:
1. System reliability
2. Service availability
4. Data integrity
1. System reliability: The system consistently
behaves in the same way.
2. Service availability: Required services are
present and usable when they are needed.
3. Confidentiality: Sensitive information is
disclosed only to those authorized to see it.
4. Data integrity: Data are not corrupted or
5. Responsiveness: The system responds to user
input within an expected and acceptable time
6. Safety: The system does not cause harm.
All computer systems are vulnerable to
both human-created threats, such as
malicious code attacks software bugs, and
natural threats, such as hardware aging
Removing all system vulnerabilities is not
practical particularly given complex,
heterogeneous environments where
software and hardware changes are a part
of routine operations.
A more practical approach to
attaining dependability is to build
tolerant systems-systems that anticipate
problems; that detect faults, software
glitches, and intrusions; and that take
actions so that services can continue
and data are protected from corruption,
destruction, and unauthorized disclosure.
Guideline 1: Architect for Dependability
A fundamental principle of system
architecture is that an enterprise system
architecture should be developed from the
bottom up so that no critical component is
dependent on a component less trustworthy
At the bottom of the architecture are the
physical and logical networks that support the
enterprise and provide the “pipes” that carry
data from system to system.
Guideline 1: Architect for Dependability
While these applications provide services that
are critical to assuring px’s privacy and
safety, these services are only as
dependable as the system services on
which they depend. In particular, operating
systems provide system-level security
functions that are critical to assuring that
individuals can access only those resources
for which they are authorized.
Guideline 2: Anticipate Failure
As computers are getting faster, systems are getting
more complex and design flaws are becoming a
In anticipation of failures at the infrastructure level,
features that are transparent to software
applications should be implemented to detect
faults, to fail over to redundant components when
faults are detected, and to recover from failures
before they become catastrophic.
Another effect of increasing complexity is an increase
in vulnerabilities which serve as “opportunities” for
Safety-critical systems should be designed and built to
fail in a safe state.
Guideline 3: Anticipate Success
The systems planning process should anticipate
business success and the consequential need for
larger networks, more systems, new applications, and
Modeling of use-case scenarios that anticipate
hospital and clinic mergers, acquisitions, and a
growing patient/customer base will enable the
system designer to visualize the data flows, system
loading, and network impact resulting from business
growth and success.
Such models and provide valuable input into
planning for scalability and future integration.
Guideline 4: Hire Meticulous Managers
Managing and keeping complex networks
and integrated systems available and
responsive requires meticulous oversees
individuals who know that failures will occur
and accept that failures are most likely to
occur when they are least expected.
They take emergency and disaster
planning very seriously; they develop, maintain,
and judicious exercise plans and procedures
for managing emergencies and recovering
Guideline 5: Don’t Be Adventurous
One should use only proven
methods, tools, technologies, and
products that have been in
production, under conditions, and at a
scale similar to the intended
The enterprise with a requirement for
dependable systems should not be the
first (or second) to adopt a new
This assessment is by no means
“scientific,” nor is it intended to represent
“all” healthcare provider organizations.
Rather it conveys observations of the
healthcare industry as a whole and the
opinions of a passionate advocate of
dependable systems for healthcare.
For adherence to the first guideline
“architecture for dependability” the clinical
care provider community gets a barely
passing grade of “D”.
Healthcare organizations build or
perhaps “compose” their systems from top
down rather than from the bottom up.
These systems are familiarly known as
"Departmental" systems because they
generally are used only in one department,
such as registration, laboratory or
The Health Insurance Portability and
Accountability Act (HIPAA) security
regulation prescribes administrative,
physical, and technical safeguards.
This safeguards contributes to system
dependability and for protecting the
confidentiality and integrity of health
information and the availability of critical
The following represent important
operational practices that clearly will
contribute to system dependability:
Eight Required Administrative Safeguards
And Five Specified Physical Safeguards
1. Security management, including
security analysis and risk management
2. Assigned security responsibility
3. Information access
management, including the isolation of
clearinghouse functions from other
4. Security awareness and training
5. Security incident procedures, including
response and reporting
6. Contingency planning, including data
backup planning, disaster recovery
planning, and planning for emergency
8. Business associate contracts that lock in
the obligations of business partners in
protecting health information to which they
may have access.
1. Access control, including unique user
identification and an emergency access
2. Audit controls
3. Data integrity protection
4. Person or entity authentication
5. Transmission security
In a healthcare environment, access must
be more liberally authorized than in many
other security environments because
access to information is a prerequisite to
care. Unfortunately, healthcare enterprises
view security as a “compliance” issue and
not a core business need. Until the
healthcare industry recognizes information
security as a core business requirement,
enterprise system dependability will not be
Medical technology and prescription
drugs are required to undergo extensive
validation before they can be used in
Computers are increasingly being used
in safety-critical clinical applications and
without careful and appropriate
attention to software safety, we can
reasonably expect that failures will
contribute to the loss of human life.
Healthcare organizations definitely expect
their computer systems to work.
However, healthcare organizations do not
foresee that their business success may
increase their need for processing power
and networking capability. Nor do they
foresee mergers’ and acquisitions’ creating
the need to consolidate their systems with
those of another healthcare enterprise.
IT managers who recognize the strong
relationship between system
dependability and the quality of patient
care implement fault-tolerant systems
with strong security protection,
middleware to manage workload and
tools to continuously monitor the health
and performance of their systems.
Healthcare clinicians are typically very resistant
to change because they are taught to
circumspect in considering new approaches,
treatment, protocols, and drug regimens.
Before adopting any new idea, they
investigate it. For dependable IT, the
healthcare practitioner’s skepticism is a good
Newness and change are anathema to
stability. While well planned executed changes
over time are desired and expected,
healthcare provider organizations should not
be overly eager to adopt
Clinical Nursing Visibility from NATIONAL
to INTERNATIONAL context:
-There’s a recognition of growing
needs for Nursing Data but has been
fuelled by International as well as
-The identification of NMDSvisionary
work begun in the US by Werley and
Lang and has spurred activity to develop
similar data set around the world.
The NMDS identifies
essential, common, and core data
elements to be collected for all
patients/clients receiving nursing care.
The NMDS is a standardized approach
that facilitates the abstraction of these
minimum, common, essential core data
elements to describe nursing practice
(Werley and Lang, 1988) from both
paper and electronic records.
The NMDS was conceptualized through
a small group work at the nursing
information systems (NISs) conference
held in 1977 at the University of Illionois
College of Nursing (Newcomb, 1981).
Werley and colleagues took the NMDS
forward at the NMDS conference in 1985
held at the University of Wisconsin –
Milwaukee School of Nursing.
NMDS includes 3 broad categories of
1. Nursing Care
2. Patient Demographics
3. Service Elements
1. Access to comparable, minimum
nursing care, and resources data on local,
regional, national, and international levels
2. Enhance documentation of nursing
3. Identification of trends related to
patient or client problems and nursing care
4. Impetus to improved costing of nursing
5. Improved data for quality assurance
6. Impetus to further development and
refinement of NISs
7. Comparative research on nursing
care, including research on nursing
diagnoses, nursing interventions, nursing
outcomes, intensity of nursing care, and
referral for further nursing services
8. Contributions toward advancing
nursing as a research-based discipline
- The early NMDS work in the United
States spurred the development of
NMDSs in numerous other countries.
- To date seven countries have
identified NMDS systems, including
Australia, Canada, Belgium, Iceland, The
Netherlands, Switzerland, and Thailand.
- Several countries across most countries beyond
North America are exploring development of NMDS’s
systems: for example, in Europe.
-The World Health Organization has been concerned
with variable including nursing care, personal data,
medical diagnosis, and services data.
-Work is ongoing in the United Kingdome, e.g.,
Scotland, to identify NMDSs to be congruent with the
initiatives of the National Health Service. The Nordic
countries likewise have much ongoing activity to identify
NMDSs, e.g.. Finland
-France also is pursing identification of a NMDS
Call for Standardized Contextual Data:
- Ample studies have demonstrated the
significance of nurse staffing, patient/staff
ratios, professional autonomy and
control, organizational characteristics, unit
internal environment, work delivery
patterns, work group characteristics, external
environment, staff work satisfaction, education
of staff, multidisciplinary
coordination/collaboration, and educational
level on the quality and outcomes of patient
Call for Standardized Contextual Data:
-The development within the United
States of the NMMDS addresses this void.
The 18 NMDS elements are organized
into three categories: environment,
nursing care resources, and financial
resources. The NMDS most appropriately
focuses on the nursing delivery
unit/service/center of excellence level
across these settings.
Call for Standardized Contextual Data:
-The NMMDS support numerous constructed
variables as well as aggregation of data, e.g,,
unit level, institutional, network, system. This
minimum data set provides the structure for the
collection of information that influences quality
of patient care, directly and indirectly. These
data, in combination with actual patient data
identified in the NMDS support clinical decision
making: management decisions regarding the
quality, quantity, and satisfaction of personnel;
cost of patient care; clinical outcomes; and
internal and external benchmarking.
Evolution of Concept:
-The i-NMDS the core, internationally
relevant, essential, minimum data elements
to be collected in the course for providing
nursing care. Work toward the i-NMDS is
intended to build on the efforts already
underway in individual countries.
-It is imperative that the national
healthcare infrastructure supports the
collection and reuse of nursing data.
Evolution of Concept:
-The i-NMDS project is intended to build on
and support data set work already underway in
individual countries, as well as the work with
another ICN initiative, the ICNP. Data collection
in the i-NMDS pilot project will be cross mapped
and normalized to the ICNP.
-This i-NMDS work will assist in testing the i-
NMDS and also advancing the ICNP as a unifying
framework .Overall, the i-NMDS project focuses
on coordinating ongoing international data
collection and analyses of the i-NMDS to support
the description, study, and improvement of
- The i-NMDS Research Center is lead by
steering committee of international
representative of countries with existing and
emerging NMDS as well as professional
cosponsorship and areas of informatics
- The project is consponsored by the ICN
and the IMIA NI-SIG. Project work is Also
coordinated with international standards
organizations and other stakeholders to
assure harmonization of these efforts.
· Describing human phenomena, nursing
interventions, care outcomes, and resource consumption
related nursing services
· Improving the performance of health care system
and the nurses working within these systems worldwide
· Enhancing the capacity of nursing and midwifery
· Addressing the nursing shortage, inadequate working
conditions, poor distribution and inappropriate utilization
of nursing personnel, and the challenges as well as
opportunities of global technological innovations
· Testing evidence – base practice improvements
· Empowering the public internationally
- The i-NMDS elements are organized into three
categories: setting, subjects of care, and nursing elements.
Setting variables include country characteristics as well as
descriptions of the location of care, whether the setting is
acute, ambulatory, home, and so on.
- Measures include care personnel characteristics,
including numbers, full-time equivalents, education,
gender, and so on. Subjects of care can include
individuals, families, groups, or communities.
Demographics of the subject (individuals, families, groups,
and communities) are included, e.g., country of
residence, disposition, age, gender, medical diagnosis
are described. Last nursing care elements included.
- Last, nursing care elements include
nursing diagnosis/subject of are
problems, interventions, and outcomes. A
measure of intensity of recourses
consumption will be developed. Nursing
care data may be collected using
standardized languages., Clinical Care
(CCC), Omaha, NANDA, NIC, NOC. All
nursing care data will be normalize using
- The power NMDSs to describe nursing
practice from an international perspective is
daunting. Knowing the human phenomena
served by nursing, the interventions given and
the outcomes realized are essential to
improved outcomes, assuring patient/client
safety, and providing wise stewardship of all
resources, from human to financial.
- Information and knowledge are key to
supporting an essential knowledge-driven
professional service and improving healthcare
through effective policy changes.