Evolving Role of Nursing Informatics Specialists in Connected Health

Evolving Role of the Nursing Informatics
Specialist
Lynn M. NAGLEa, Walter SERMEUS b, Alain JUNGERc
a
Lawrence S. Bloomberg, Faculty of Nursing, University of
Toronto, Toronto, Ontario,
Canada
b
Leuven Institute for Healthcare Policy, University of Leuven,
Belgium
cUniversity Hospital of Lausanne, Lausanne, Switzerland
Abstract. The scope of nursing informatics practice has been
evolving over the
course of the last 5 decades, expanding to address the needs of
health care
organizations and in response to the evolution of technology. In
parallel, the
educational preparation of nursing informatics specialists has
become more
formalized and shaped by the requisite competencies of the role.
In this chapter,

the authors describe the evolution of nursing informatics roles,
scope and focus of
practice, and anticipated role responsibilities and opportunities
for the future.
Further, implications and considerations for the future are
presented.
Keywords. Nursing informatics specialist, role function,
connected health, data
science, big data, personalized medicine, clinical intelligence,
virtual care
1. Introduction
By 2018, 22 million households will use virtual care solutions,
up from less than a
million in 2013. Average (healthcare) visits among these
adopter households will
increase from 2 per year in 2013 to 6 per year in 2018, which
include both acute care
and preventive follow-up services in a variety of care settings—
at home, at retail kiosk
or at work. [1]
Nursing informatics roles have taken many forms in focus and
function over the
last decades; suffice it to say that they have not been
consistently described or defined

in terms of scope of practice. At the time of this writing it is
clear that role of nursing
informatics specialists will continue to evolve at an increasingly
rapid rate in the
coming years. The unfolding of new health care paradigms will
bring greater
connectivity between care providers and patients, include a
wide array of emerging
technologies and an increasing emphasis on data analytics will
make the integration of
informatics competencies into every area of nursing an
imperative.
2. Brief history of roles of the past and present
The earliest and most common types of informatics work
assumed by nurses has
included: oversight of organizational workload measurement
systems, project
leadership, systems educator, and nursing unit or departmental
information technology
resource. In many instances, these roles were enacted on the
basis of a specific
identified organizational need and were often secondments to
the Information

Technology Department. It was not unusual for these roles to
have the designation of
Forecasting Informatics Competencies for Nurses in the Future
of Connected Health
J. Murphy et al. (Eds.)
© 2017 IMIA and IOS Press.
This article is published online with Open Access by IOS Press
and distributed under the terms
of the Creative Commons Attribution Non-Commercial License
4.0 (CC BY-NC 4.0).
doi:10.3233/978-1-61499-738-2-212
212
“IT nurse” [2]. As role responsibilities and job titles have been
widely varied, so have
the qualifications for each. The need for more specificity and
consistency in nursing
informatics roles has been recognized for several years [3, 4, 5].
The advent of formal education programs for nurses interested
in specializing in
informatics has occurred in conjunction with increasing
sophistication in the use of
information and communication technologies (ICT) in clinical
practice settings. Today,

nurses have the option to pursue specialization and credentials
at a variety of levels
including graduate specialization and specialty certification.
Advanced credentials and
certification (e.g., Certified Professional in Healthcare
Information and Management
Systems - CPHIMS) have afforded nurses the opportunity to
achieve credibility and
legitimacy regarding the specialty informatics knowledge and
skills they bring to bear
in nursing practice and academia and healthcare in general [6].
This credibility has
been recognized with the development of executive level
positions such as the “Chief
Nursing Informatics Officer” (CNIO) in some countries. The
position of the “Chief
Medical Informatics Officer” (CMIO) is much more prevalent
and deemed essential in
medium and large health care organizations while the C-level
nursing counterpart
remains less common. Several authors [7-11] have described the
role and competencies
for these senior informatics positions, yet the valuing of these
positions remains limited

among health care provider organizations.
In addition to the evolution of formalized training programs for
nurses interested in
informatics, the specialty of nursing informatics has continued
to evolve and has
become recognized in local jurisdictions, nationally and
internationally. Groups of like-
minded nurses have organized into special interest groups
affiliated with larger
interdisciplinary organizations (e.g., International Medical
Informatics Association -
Special Interest Group on Nursing Informatics (IMIA-NI-SIG)).
Organizations such as
the Canadian Nursing Informatics Association (CNIA), the
American Nursing
Informatics Association (ANIA), the Nursing Informatics
Working Group of the
European Federation for Medical Informatics (EFMI-NURSIE)
are examples of forums
for nurses to network, collaborate and profile their work in
informatics. The existence
of these specialty organizations has served to further legitimize
the work of nurse
informaticians and provided a venue for advancing regional,

national and international
efforts in nursing informatics. Through conferences, meetings
and the offering of
educational sessions, virtually and face to face, these networks
of nurse informaticists
have collectively advanced the practice and science of nursing
informatics. A case in
point is the International Nursing Informatics Congress and
post-conference, now held
bi-annually and hosted by countries across the globe. Outputs of
these meetings include
publications such as this one; benefitting nursing informatics
specialists and the nursing
profession worldwide.
At the time of this writing, we find nursing informatics
specialists in virtually
every clinical practice setting. The roles and focus of their work
endeavors are wide
and varied. The titles of “informatics nurse”, “nurse
informatician”, and “nursing
informatics specialist” are but a few of the titles applied to
nurses working in the field.
Many of the roles of the past and present have been more
extensively described

elsewhere [2,12]. For the purpose of this chapter, the authors
use the title of nursing
informatics specialist to provide illustrations of the potential
focus of these roles
current and future.
Roles to date have largely focused on supporting acquisition,
implementation and
evaluation of clinical information systems in health care
organizations. As noted by
McLane and Turley [4], “informaticians are prepared to
influence, contribute to, and
mold the realization of an organization’s vision for knowledge
management” (p.30).
L.M. Nagle et al. / Evolving Role of the Nursing Informatics
Specialist 213
Nurses have been in pivotal roles at every step of the systems
life cycle and
instrumental in the success of deployments at every level of an
organization. From the
provision of executive oversight, project management, systems
education and training,
and analytics, nurses in clinical settings have become core to

organizations’
information management infrastructure and support.
In addition to health care provider organizations, nursing
informatics specialists
can be found in the employ of technology vendors, retail
outlets, and consulting firms
while many others have created their own entrepreneurial
enterprise. Over the last few
decades, technology vendors, hardware and software, have come
to appreciate the
invaluable contribution of nurses to the development, sales and
deployment of their
solutions. Throughout the world, nurses are also engaged in
academic pursuits to
advance the knowledge base of nursing informatics through the
conduct of research.
Efforts are underway in many countries to advance the adoption
and integration of
entry-to-practice informatics competencies into undergraduate
nursing programs.
Notwithstanding some of the ongoing gaps in the provision of
informatics content in
undergraduate nursing education, many courses and programs
have been taught in a

variety of post-secondary education institutions over several
years by nursing
informatics specialists. In fact it is not unusual for many nurses
to develop an interest
in informatics through a single course and subsequently pursue
further studies and
employment opportunities.
Since the early 90’s many graduate level courses and degrees,
certificate and
certification programs have been developed and offered world-
wide. Nurses have
pursued these opportunities recognizing the necessity of
informatics knowledge and
skills now and particularly into the future, as they face an
increasingly connected world
of digital healthcare. To a large extent, the core competencies
of the nursing
informatics specialist have become essential for all nurses and
expectations of the
specialist role will continue to evolve even further.
3. Emerging roles for nursing informatics specialists
The healthcare sector continues to evolve in the application and
use of technologies to

support the delivery of care. Factors including: a) rising health
care expenditures, b) the
increasing incidence of chronic disease, c) the ubiquity of
technology, d) an aging
demographic, e) personalized medicine, f) mobile and virtual
healthcare delivery, g) the
emergence of consumer informatics, h) genomics, i) big data
science, and connected
health are and will continue informing the evolution of nursing
informatics roles.
One of the main challenges we have to cope with is the
difference in growth rate
that is exponential for the new technology and knowledge yet is
still linear for
changing human behavior, learning, organizations, legislation,
ethics, etc, A linear
growth rate is mostly represented by a function in a form like
y(x) = ax+b. An
exponential growth rate is mostly represented by a function in a
form like f(x) = kax.
For example: In an exponential world where the information is
doubling every year, 5
exponential years would equal to 25 or 32 linear years which
has a massive impact on

the management of professional knowledge. In reality, we
estimate that knowledge
development in healthcare, which has doubled every century
until 1900, is now
estimated to double every 18 months. And the pace is getting
faster. This means that
when nurses finish their education, the knowledge they gained
might be already
outdated. The traditional way of developing procedures,
protocols and care pathways,
sometimes requiring a year to develop, are outdated when they
are finalized and are
Specialist214
insufficient to guide future practice. The only way forward is to
integrate and embed
the new knowledge in electronic patient records using
algorithms and decision support
systems so that practice remains aligned with new knowledge
and insights. The impact
might be that best practices can change very quickly and what is
viewed as best

practice before your holiday leave might be different upon your
return to work. Making
the connection between these different dimensions of time will
be a key-role of the
evolving role of the NI specialist.
A second challenge is that clinical practice in the future will be
largely team based.
The nature of teams will include interprofessional teams,
patients and their relatives
and a wide range of virtual devices (internet of things - IoT)
that are all connected.
Teams will work across boundaries of organizations and will be
organized around a
particular patient. We still have to come up with new labels for
naming these temporary
virtual interprofessional patient teams. Practically it will mean
that nurses will be
(temporary) members of different teams at the same time. This
notion of teamwork is
in contrast with what we normally see as teams organized in
organizations, departments
and units. It will challenge how teams will be managed, led, and
evaluated. But it will
also challenge the communication within teams and the

exchange of information.
3.1 Virtual and connected care
The delivery of health services virtually is becoming
commonplace in many places
around the globe. Virtual care has been defined as: “any
interaction between patients
and/or members of their circle of care, occurring remotely,
using any forms of
communication or information technologies, with the aim of
facilitating or maximizing
the quality and effectiveness of patient care” [13, p 4].
The most common modalities of virtual care are currently in use
in telemedicine.
Telemedicine has been largely used to conduct remote medical
consultations,
assessments and diagnosis (e.g., teledermatology, telestroke,
telepsychiatry) through
the use of computer technology and associated peripheral
devices including digital
cameras, stethoscopes and opthalmoscopes, and diagnostic
imaging. More recently, the
tools of telemedicine have been extended to the provision of
remote nursing monitoring

and assessment particularly for individuals with chronic
diseases such as congestive
heart failure (CHF) and chronic obstructive pulmonary disease
(COPD). The nurses
providing these tele-homecare services are not necessarily
informatics specialists but
the design and management of the monitoring tools,
infrastructure and support services
may be provided by them in the future.
Another emerging area of nursing informatics practice will
likely focus on the use
of remote monitoring technologies such as sensors and alerts
embedded in structures
(e.g., flooring, lighting, furniture, fixtures) and appliances (e.g.,
stove, refrigerator) in
the homes of citizens. These tools offer the promise of
supporting seniors to maintain a
level of independence in their own homes longer, particularly
those with cognitive or
sensory impairments. Such devices might trigger direct
messaging to providers, lay and
professional, flagging potentially harmful situations and
affording early intervention as
necessary. Different types of sensors (e.g., sleep, activity,

falls, ambulation,
continence, fluid and electrolyte) will also contribute new
supplementary data to health
information repositories, offering the possibility of linking to
other data sets and
provide new insights to the well-being of individuals in the
community especially the
aged and those living with chronic illness.
With the increasing use of consumer health solutions such as
patient portals and
smartphone apps for self-monitoring and management of health
and disease, nurse
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informatics specialists will likely play a key role in their
support and development.
From the perspective of application design and usability, and
training, nursing input
and informatics expertise will be important to ensure
appropriate and safe use of these
tools. As individuals and their families become more active
participants in their care

through the use of applications and devices to connect with
providers, they will likely
also need expertise and support from the nursing informatics
specialist.
3.2 Knowledge generation and innovation
The traditional ways of new knowledge generation is through
research and the
dissemination of findings in research journals. Knowledge is
consumed by researchers
and clinicians who transform it into relevant guidelines and care
pathways. The time
between the generation of research findings and application in
the real clinical work
can take several years. It is generally estimated that it takes an
average of 17 years for
research evidence to reach clinical practice [14]. Therefore
clinicians are not always
aware of existing evidence. In a landmark study, McGlynn et al.
[15] evaluated the use
of evidence-based guidelines in 30 conditions and 439
indicators for the use of the
same. They showed that clinicians (doctors, nurses) only apply
50% of them in their
daily practice. The use varied from 80% for structured

conditions such as cataract to
10% for unstructured conditions such as alcohol addiction.
There is also a lot of
research demonstrating that nurses lack knowledge related to
common procedures.
Dilles study illustrated [16] that nurses lack sufficient
pharmacological knowledge and
calculation skills. Baccalaureate prepared nurses’
pharmacological knowledge averaged
between 60% and 65% of the level expected. Segal et al. [17]
analyzed the use of hip
arthroplasty care pathways in 19 Belgian hospitals finding a
high variability in
providing evidence-based interventions. While post-op pain
monitoring is in 100% of
the care pathways, pre-op physiotherapy was only present in
25% of the care pathways.
In the future of connected health, there will be direct links to
knowledge generated
by specialists from around the world. New knowledge will be
automatically integrated
and embedded into electronic patient records, and include new
algorithms for decision
support systems. It is interesting to note that Hearst Health

Network, one of the largest
media and communication groups in the world, is taking a
leading role in healthcare.
They started an intensive collaboration among strong health
knowledge companies
such as First Databank (FDB), Map of Medicine, Zynx Health
and Milliman Care
Guidelines (MCG). FDB is a United Kingdom company
specialized in integrated drug
knowledge to prescribe medication, follow-up drug interactions,
improve clinical
decision making and patient outcomes. Map of Medicine was
created in the UK for
clinicians by clinicians. It offers a web-based visual
representation of evidence-based
patient journeys covering 28 medical specialties and 390
pathways. Zynx Health offers
a similar story from the US to provide evidence-based clinical
decision support system
solutions at the point of care through electronic patient records.
MCG produces
evidence-based clinical guidelines and software and is widely
used in the US, UK and
Middle East. Other examples of health information networks are

CPIC (Clinical
Pharmacogenetics Implementation Consortium) to help
clinicians understand how
available genetic test results could be used to optimize drug
therapy, the International
Cancer Genome Consortium (ICGC) which facilitates data
sharing to describe genomic
sequences in tumor types among research groups all over the
world. In the information
models, such as archetypes and Detailed Clinical Models (see
section C chapter 1) offer
summaries of evidence for specific clinical concepts.
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Likely one of the most significant areas of focus for nursing
in the near term is data science and the use of “big data”. Big
data has been defined as:
“large amounts of data emerging from sensors, novel research
techniques, and
ubiquitous information technologies” [18, p. 478]. Access to big
data unveils a whole

new sphere of informatics opportunities related to health and
nursing analytics.
According to Masys [19], big data is “that which exceeds the
capacity of unaided
human cognition and strains the computer processing units,
bandwidth, and storage
capabilities of modern computers”. The future development of
nursing capabilities in
data science will essentially lead to an entirely new cadre of
nursing informatics
specialists whose work will focus on deriving new nursing
knowledge from not only
electronic health record data, but also the data from sensor and
remote monitoring
technologies, patient portals and mobile apps described above.
The implications of -
omics data such as genomics, metabolomics, and proteomics,
being included as part of
the electronic health record in the near future, should be taken
into account. Nurse
informatics specialists will be pivotal in assisting to identify
potential ethical and
practice implications in the use of these data.
Using big data, the knowledge generating process might be

reversed into practice-
based evidence where data from electronic health records,
patient portals, sensors etc.
are uploaded into large databases that identify patterns and
clinical interesting
correlations. An example of the power of analyzing large
datasets is the Vioxx-case
(rofecoxib). Although a clinical trial initially showed no
increased risk of adverse
cardiovascular events for the first 18 months of Vioxx use, a
joint analysis of the US
FDA and Kaiser Permanente’s Healthconnect database of more
than 2 million person-
years of follow-up, the NSAID arthritis and pain drug was
found shown to have an
increased risk for heart attacks and sudden cardiac death. [20]
After the findings were
confirmed in a large meta-analysis, Merck decided to withdraw
the drug from the
market worldwide in 2004.
With the proliferation of these emerging data sources and
databases, the nursing
informatics specialist will play a key role in the use of these
data to inform quality and

safety improvements in every practice setting.
3.3 Sharing knowledge and communication
In the realm of the new normal of connected health, nurses will
work in temporary
teams around patients. Within these teams it will be essential
that goals are clear and
shared, that roles are defined and accepted and that the way of
working is clear to
everyone. It requires systems for coordination and
communication to ensure the
continuity of care. Reid et al. [21] defined continuity of care as:
"how one patient
experiences care over time as coherent and linked; this is the
result of good
information flow, good interpersonal skills, and good
coordination of care". They
make a distinction between information continuity, relational
continuity and
management continuity. Information continuity consists on one
hand in the exchange
and transfer of information among health care providers and to
patients and on the
other hand how the knowledge of the patient is accumulated. It

is about their specific
knowledge, preferences, expectations, social network. With the
existence of the new
technology of the quantified self, it is important that these new
data are effectively
integrated and connected. Relational continuity consists of the
trusted relationship
between patient and healthcare provider. Increasingly advanced
practice nurses are
assuming this pivotal role within the health team. Management
continuity is referring
to a consistent and coherent approach to the health problem
across organizations and
Specialist 217
boundaries. The Belgian healthcare system offers an interesting
example of this:
General Practitioners are stimulated (financially) to prescribe
generic drugs. Hospitals
are stimulated to negotiate discounts with pharmaceutical
companies leading to brand
named drug choices. Although they might chemically be
identical, for the patient they

often are not as they have different names. Like drugs may be
different in size and
color leading to more medication errors as patients may take
two pills without being
aware that they are the same drug.
Although nurses spend a lot of time documenting care, the
accuracy of nursing
documentation has been found to be poor. In a study within 10
Dutch hospitals, Paans
et al. [22] found that within 341 patient records the accuracy of
documentation of
diagnoses was poor or moderate in 76% of the records. The
accuracy of the
intervention documentation was poor or moderate in 95% of the
patient records. Only
the accuracy for admission, progress notes and outcomes
evaluation and the legibility
were acceptable. The work of Connected Health should support
the documentation
systems of nurses and other health professionals. The use of
structured documentation
methodologies and standardized terminologies should improve
the quality of the

patient record and improve the capacity for comparability of
care processes and
outcomes across the care continuum and within patient care
groups.
3.4 Impact of connected health on the Scope of Practice of
Nurses and Advanced
Practice Nurses (APN)
In Connected Health, the scope of practice of nurses will
change. For example, based
on time and motion studies, it has been shown that nurses spend
5-7% of their time [23,
24] collecting vital sign data. In the future this work will be
assimilated by sensors and
other devices. However, nurses’ work will be more focused on
analyzing the data and
evaluating thresholds for action (e.g., alerting rapid response
teams). Another example
is the use of sensors for pressure ulcer monitoring [25]. The
used sensors will provide
information about patient temperature, skin humidity, pressure
points and position.
These data will generate a whole new set of information for
review and action
including pressure intensity map and humidity intensity maps.

These data would lead to
more precise management of pressure sores. Other examples of
data gathering that will
change the focus and processes of nurses’ work include:
barcode scanning for checking
identity of patients, patient and device tracking systems, and
robotic dispensing of
medication.
Patient access to their own records and partnering in their own
health will change
the roles of physicians, nurses and hospitals drastically. The
work of nurses will
increasingly shift from a direct care provision to the role of
knowledge broker in
helping patients to understand care alternatives, manage their
health, and navigate
information access.
4. Impact of connected health on the evolving role of the
Nursing Informatics
Specialist
Connected health will alter the future role of the nursing
informatics specialist and
require a new set of competencies. To a large extent these

competencies will build
upon existing competencies but have an increasing emphasis on
information use rather
than technology use. Table 1 provides a summary of the
anticipated new competencies
Specialist218
and role responsibilities that are likely to be necessary for
Nursing Informatics
Specialists in the emerging world of connected health and the
IoT.
Table 1. New competencies related to the future role of nursing
New Competencies New Roles
Knowledge Innovation and
Generation
• Provide guidance and support to others (nurses, patients) in
the
application and use of emerging knowledge (e.g., clinical
decision
support, Practice-Based Evidence (PBE), genomics, expert and

patient/citizen knowledge)
• Inform-teach others (clinicians, teams, patients) about new
knowledge and knowledge innovations relevant to specific
situations
• Provide direction and support to others in the use of
international
guidelines and knowledge
• Contribute internationally to new knowledge generation and
innovations ensuring the inclusion of relevant team member and
patient perspectives and expertise
Monitoring the use of new
technology
• Monitor and maintain vigilance over data/technologies to
identify
those that add value to a given health situation.
• Recognize that nurses, other clinicians and patients may
engage and
assume responsibility independently and or interdependently for
specific data (e.g., remote monitoring, self-monitoring,
wearables,

appliances).
• Recognize the emergence of patient self-service and relevance
of
patient expertise in specific situations.
Value judgement & quality
assessment
• Provide guidance as to the value and relevance of specific data
and
information as derived from single or multiple sources for any
given
set of circumstances, or health situations.
Change Management • Identify the broader scope and
considerations for change
management in the context of connected health (e.g., virtual and
physical participants/partners)
• Recognize the extended complexities of technology adoption
in the
context of connected health.
Communication &
Documentation

With increasingly complex and personalized approaches to
health care,
participate in the identification and/or development of new:
• models of clinical documentation
• methods of communication
• data standards
• terminology standards
• data sources
• data models
• data repositories
Data Analytics In addition to traditional quantitative and
qualitative analyses, support
and participate in the development and use of new approaches
and
methods of data analytics for:
• knowledge generation (e.g., natural language processing,
experiential data)
• reporting outcomes
• demonstrations of value (e.g., patient-caregiver perspectives,
health

and financial outcomes)
• predictive and retrospective analyses
Specialist 219
5. Conclusion
The future Nursing Informatics Specialist will function in the
context of virtual care
delivery, be informed by data aggregated from a multiplicity of
sources and real-time
knowledge generation that will inform individualized care. In
addition to the
competencies required to date, they will be required to support
other clinicians and
patients and families as they assume new roles and use data
analytics to interpret and
appropriately apply new knowledge. With the IoT, connected
care will pose as yet
unknown challenges for the Nursing Informatics Specialist in
the future; what is certain
is that the role will continue to evolve from the role scope and
responsibilities known

today.
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[21] Reid R., Haggerty J., McKendry R. (2002). Defusing the
Confusion: Concepts and Measures of
Continuity of Healthcare. Canadian Health Services Research
Foundation.
[22] Paans W, Sermeus W, Nieweg RM, van der Schans CP.
(2010) Prevalence of accurate nursing

documentation in patient records. J Adv Nurs. Aug 23, p. 1365-
2648
[23] Mendonck K., Meulemans H., Defourny J. (2000), Tijd
voor zorg: een analyse van de zorgverlening in
de gezondheids- en welzijnssector, VUB Press, 126pp.
[24] Hendrich A, Chow MP, Skierczynski BA, Lu Z. (2008). A
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Specialist 221

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Running Head: ARTICLE WRITING3
Name
Instructor
Course
Date
Article writing
Paper 1
Following my sending on compulsory leave to pave
way for a conclusive investigation in what the Human
Resources Manager termed as insubordination at the workplace,

I intend to let you know that I have discovered that you played a
significant part in influencing the Human Resource Manager’s
decision. As my work colleague and once a trusted friend, we
both know that this is a baseless propaganda in which I am yet
to ascertain the motives. I have also discovered that you
approached the manager with allegations that besides verbally
and openly questioning the integrity and trust of our team
leader, I defied and worked towards opposing any instructions
given by the team leader in the presence of fellow colleagues.
My biggest concern is that I feel hurt, betrayed and
displeased not by the manager’s decision to send me on
compulsory leave but because of your significant input in the
allegations. What makes me feel even more disappointed is the
fact that you and I both know that I am not that type of an
employee who would risk it all to damage the reputation of a
team leader without any evidence to support my case. I am not
certain of what your motives were in propagating this
propaganda but surely I feel pain not necessarily because I will
be out of work for the next six months pending the
investigations but because of the impact that this move will
have on my career going forward irrespective of whether or not
the findings of the investigation will come in my favor.
For the sake of honesty, our relationship as friends and
colleagues and the pain you would have to endure if the
evidence you have against me proves to be insufficient, I would

request you to take the appropriate action and initiative of
approaching the Human Resources Manager as well as the team
leader informing them that it was just a misunderstanding and
that you and I are going to resolve any issues that could have
led to such allegations.
Paper 2
As my family doctor and therapist, I feel obliged to let
you know that all has not been well with me over the last couple
of months since I was sent on compulsory leave pending
investigations relating to insubordination issues. For your
information and for the sake of sincerity, I had nothing to do
with insubordination. However, for the record, I have a history
of fighting for the rights of people whom I feel are mistreated
with no exception of fellow employees whom I feel are
discriminated against and mistreated in terms of remunerations,
promotions among others. My colleague and I have been friends
since high school. In fact, we have been competing in almost all
aspects of life; academics, sports, job performance, business
and success in life. I believe and I am fully convinced that the
allegations were triggered by the fact that I was in the verge of
securing a promotion to becoming a team leader. This was an
attempt to stop the promotion.
The fact that I have been jobless since I was
suspended has done more bad than good. I have been dealing
with emotional pain, extreme stress, feelings of betrayal,

inability to settle bills, sleepless nights, headaches (sometimes
migraines), loneliness and loss of appetite. As a matter of fact, I
have had suicidal ideation on several instances since I was
suspended from work. I have been hospitalized once since then
and diagnosed with depression.
I believe you are not aware that as a teenager I had also
been diagnosed with depression and Post Traumatic Stress
Disorder after an accident that claimed the life of my best
friend. I also had the same suicidal ideation following that
incident to the extent of taking a whole bottle of whisky all by
myself. Certainly, I need the investigation to conclude so that I
can know my fate. This is the only way to move forward.
OnlineJournal of NursingInformatics: Volume 21, Winter 2017
Contents
1. Featuring the work of:
2. Manuscripts
3. Fact-Finding Survey on the Operational Status of Electronic
Medical Record Systems in Japan
4. A Comparison of Professional Informatics-Related
Competencies and Certifications
5. Student Manuscripts
6. Healthcare Informatics
7. Policy Statement: Texting in Health Care
8. Using an Electronic Health Record to Standardize

Documentation in an Emergency Observation Unit
9. Needs Assessment of an Electronic Health Record at an
Inpatient Psychiatric Hospital
10. Nursing Informatics and the Metaparadigms of Nursing
11. Do Clinical Decision Support Systems Reduce Inappropriate
Antibiotic Prescribing for Acute Bronchitis?
12. Editorial Columns
13. Successful submissions: Helpful Editor Tips
14. Senior Editor Columns
15. National Efforts in 2016 to Improve Health IT Usability
16. Training Beyond Task: Organizational Policy Implications
for Competency Development
17. Making Advance Care Planning Information Interoperable at
the Point of Care: The Next Step to Genuinely Promoting
Dignified Dying
Full Text
ListenPauseStopSelect: VolumeSettingsDownload mp3Close
PlayerSpeech-enabled by ReadSpeaker
Volume 21 Winter 2017
OnlineJournal of NursingInformatics (OJNI) Winter 2017
ISSN # 1089-9758 Indexed in CINAHL © 1996 - 2017
Featuring the work of:
Kuroda, Y., Fukuda, K., Yamase, H., Seto, R., Ito, M.,
Shimomai , K., Furukawa, H., Tatsuno, J., Tado, A.,
McCormick, K., Gugerty, B., Sensmeier, J., Sweeney, J., Terry,

A., Noal, C., Thomas, L., Francis, I., Lipford, K., Jones, S.,
Johnson, K, Storck, L., Kaminski, J., Staggers, N., Makar, E.,
Keenan, G., Kennedy, M.
OJNI is transitioning to Guest Access in which you must either
login or create an account to view content from OJNI. Creating
an account is free and HIMSS membership is not required.
Please help us obtain readership demographics and create your
account today.
Manuscripts
Fact-Finding Survey on the Operational Status of Electronic
Medical Record Systems in Japan
Using a quantitative descriptive study design, the present
operational status of Japanese electronic medical record (EMR)
systems and the extent of computerized nursing record adoption
in nursing departments are identified. [Yuko Kuroda, Mitsumi
Masuda, Kazuaki Fukuda, Hiroaki Yamase, Ryoma Seto, Misae
Ito, Kimiyo Shimomai, Hidetoshi Furukawa, Junko Tatsuno,
Asami Tado].
Feb 2017
A Comparison of Professional Informatics-Related
Competencies and Certifications
This paper describes various types of professional informatics
competencies that are measured by certification standards.
[Kathleen A. McCormick, Brian Gugerty, Joyce Sensmeier].
Student Manuscripts

Feb 2017
Healthcare Informatics
This paper explores the implications that are most notable in
today's healthcare world within healthcare and
nursinginformatics fields [Julianne Sweeney].
Feb 2017
Policy Statement: Texting in Health Care
The purpose of this policy is to establish guidance on short
message service (SMS) text messaging by members of the
health care workforce, and address security risks presented by
SMS text messaging [Lisa Storck].
Feb 2017
Using an Electronic Health Record to Standardize
Documentation in an Emergency Observation Unit
This workflow redesign project identified ways to improve and
optimize patient care and reduce inefficiencies by developing a
standardized EHR documentation template for observation
patients using social, technical, and regulatory requirements
[Christina Noah, Laura Thomas].
Needs Assessment of an Electronic Health Record at an
Inpatient Psychiatric Hospital
Studies have examined different healthcare organizations' quest
to adopt a meaningful use electronic health record (EHR), but
there is a significant lack of studies conducted for inpatient
psychiatric hospital settings. The purpose of this mixed design

descriptive study was to explore one particular inpatient
psychiatric hospital's EHR and identify facilitators and barriers
to the current EHR's use [Stacey Jones, Kelly Johnson, Karen
Lipford].
Feb 2017
Nursing Informatics and the Metaparadigms of Nursing
The nursing metaparadigm is a conceptual framework that
demonstrates the interconnected nature of nursing, person
(patient), environment and health. This paper will present three
different viewpoints of technology and nursing practice; nurse
perceptions and utilization of technology within an inpatient
acute care setting, an over-arching examination of the ethicality
of the use of technology in the science of caring, and nurse and
patient perceptions of utilizing health-enabling technology in an
outpatient community setting [Isabel Francis].
Feb 2017
Do Clinical Decision Support Systems Reduce Inappropriate
Antibiotic Prescribing for Acute Bronchitis?
Clinical Decision Support (CDS) systems are tools that utilize
either electronic medical records (EMR) or paper methods to
guide the evidence-basis- for specific treatment during patient
encounters as nurse practitioners are increasingly utilizing CDS
systems as part of the care team. This integrative review of the
literature demonstrates that, when implemented correctly, CDS's
can help reduce inappropriate antibiotic prescribing by nurse

practitioners for acute bronchitis [Angela Terry].
Editorial Columns
Feb 2017
Successful submissions: Helpful Editor Tips
Since the OnlineJournal of NursingInformatics (OJNI) began 21
years ago, nurses have been encouraged to submit manuscripts
for double blind peer review. June Kaminski, RN MSN PhD(c),
Editor in Chief, OJNI, provides helpful tips and tricks for
writers who are interested in submitting a manuscript for the
OJNI.
Senior Editor Columns
Feb 2017
National Efforts in 2016 to Improve Health IT Usability
With the widespread deployment of electronic health records
(EHRs) and other electronic devices, poor health IT usability
has become a critical issue across disciplines and health
organizations. Read the insights from Nancy Staggers, PhD, RN,
FAAN, President, Summit Health Informatics and Adjunct
Professor, University of Utah and Ellen Makar, MSN, RN-BC,
CCM, CPHIMS, CENP, Senior Research Scientist, Battelle and
their discussion on the importance of nurses in informatics to
harmonize efforts to build traction in providing solutions for
nursing pain points with health IT.
Feb 2017
Training Beyond Task: Organizational Policy Implications for

Competency Development
Read how Margie Kennedy, PhD, RN, CPHIMS-CA, Chief
NursingInformatics Officer and Managing Partner, Clinical
Informatics, Gevity Consulting Inc. discusses the challenges of
change management and the implications to understand where
new solutions fits into the overall strategy of the organization,
the kinds of comparable applications and functionality used, as
well as the scope of policies governing practice use within a
new application environment.
Feb 2017
Making Advance Care Planning Information Interoperable at the
Point of Care: The Next Step to Genuinely Promoting Dignified
Dying
In the absence of preference identification for end-of-life care,
many unnecessary and costly procedures may be performed that
severely compromise the dignity of the dying patient. Senior
Editor, Gail M. Keenan, PhD, RN, FAAN, Professor and the
Annabel Davis Jenks Endowed Chair of the College of Nursing,
University of Florida, discusses the new CMS (2016)
reimbursement policy of advanced care planning visits for
Medicare patients as an important step toward implementing
care that honors the dignity of all dying patients.
American Accent

FOURTH EDITION
NURSING
INFORMATICS
and the Foundation of Knowledge
The Pedagogy
Nursing Informatics and the Foundation of Knowledge, Fourth
Edition drives comprehension
through a variety of strategies geared toward meeting the
learning needs of students,
while also generating enthusiasm about the topic. This
interactive approach addresses
diverse learning styles, making this the ideal text to ensure
mastery of key concepts. The
pedagogical aids that appear in most chapters include the
following:

Key Terms
» Accessibility
» Cognitive activity
» Data
» Data gatherer
» Enumerative
approach
» Expert systems
» Industrial Age
» Information
» Information Age
» Information user
» International
Classification of
Nursing Practice
» Knowledge
» Knowledge
builder
» Knowledge user
» Knowledge worker

» Ontological
approach
» Reusability
» Standardized Nurs-
ing Terminology
» Technologist
» Terminology
» Ubiquity
» Wisdom
1. Trace the evolution of nursing informatics from
concept to specialty practice.
2. Relate nursing informatics metastructures, con-
cepts, and tools to the knowledge work of nursing.
3. Explore the quest for consistent terminology in
nursing and describe terminology approaches that
accurately capture and codify the contributions
of nursing to health care.

4. Explore the concept of nurses as knowledge
workers.
5. Explore how nurses can create and derive clinical
knowledge from information systems.
Objectives
9781284122688_CH06.indd 104 16/12/16 5:56 PM
Introduction
Those who followed the actual events of Apollo 13, or who
were enter-
tained by the movie (Howard, 1995), watched the astronauts
strive against
all odds to bring their crippled spaceship back to Earth. The
speed of their
travel was incomprehensible to most viewers, and the task of
bringing the
spaceship back to Earth seemed nearly impossible. They were
experienc-
ing a crisis never imagined by the experts at NASA, and they
made up
their survival plan moment by moment. What brought them back
to Earth

safely? Surely, credit must be given to the technology and the
spaceship’s
ability to withstand the trauma it experienced. Most amazing,
however,
were the traditional nontechnological tools, skills, and supplies
that were
used in new and different ways to stabilize the spacecraft’s
environment
and keep the astronauts safe while traveling toward their
uncertain future.
This sense of constancy in the midst of change serves to
stabilize experi-
ence in many different life events and contributes to the
survival of crisis
and change. This rhythmic process is also vital to the healthcare
system’s
stability and survival in the presence of the rapidly changing
events of the
Knowledge Age. No one can dispute the fact that the Knowledge
Age is
changing health care in ways that will not be fully recognized
and under-
stood for years. The change is paradigmatic, and every expert
who ad-

dresses this change reminds healthcare professionals of the need
to go with
the fl ow of rapid change or be left behind.
As with any paradigm shift, a new way of viewing the world
brings
with it some of the enduring values of the previous worldview.
As health
care continues its journey into digital communications,
telehealth, and
wearable technologies, it brings some familiar tools and skills
recognized
in the form of values, such as privacy, confi dentiality,
autonomy, and nonma-
lefi cence. Although these basic values remain unchanged, the
standards for
living out these values will take on new meaning as health
professionals
confront new and different moral dilemmas brought on by the
adoption
Ethical applications
of Informatics
Dee McGonigle, Kathleen Mastrian, and Nedra Farcus

77
ChapTEr 5
9781284122688_CH05.indd 77 16/12/16 5:52 PM
Key Terms Found in a list at the
beginning of each chapter, studying
these terms will create an expanded
vocabulary.
Objectives Providing a snapshot of the key
information encountered in each chapter, the
objectives serve as a checklist to help guide
and focus study. Objectives can also be found
within the text’s online resources.
Introductions Found at the beginning of
each chapter, the introductions provide
an overview highlighting the importance
of the chapter’s topic. They also help keep
students focused as they read.
Key Terms
» Artificial

intelligence
» Brain
» Cognitive
informatics
» Cognitive science
» Computer science
» Connectionism
» Decision making
» Empiricism
» Epistemology
» Human Mental
Workload (MWL)
» Intelligence
» Intuition
» Knowledge
» Logic
» Memory
» Mind
» Neuroscience
» Perception

» Problem solving
» Psychology
» Rationalism
» Reasoning
» Wisdom
1. Describe cognitive science.
2. Assess how the human mind processes and gener-
ates information and knowledge.
3. Explore cognitive informatics.
4. Examine artificial intelligence and its relationship
to cognitive science and computer science.
Objectives
9781284122688_CH04.indd 64 16/12/16 5:46 PM
Summaries Summaries are included at
the end of each chapter to provide a

concise review of the material covered,
highlighting the most important points
and describing what the future holds.
uncertainty to the situational factors and personal beliefs that
must be considered cre-
ates a need for an ethical decision-making model to help one
choose the best action.
Ethical Decision Making
Ethical decision making refers to the process of making
informed choices about ethical
dilemmas based on a set of standards differentiating right from
wrong. This type of
decision making reflects an understanding of the principles and
standards of ethical
decision making, as well as the philosophic approaches to
ethical decision making,
and it requires a systematic framework for addressing the
complex and often contro-
versial moral questions.
As the high-speed era of digital communications evolves, the
rights and the needs
of individuals and groups will be of the utmost concern to all

healthcare profession-
als. The changing meaning of communication, for example, will
bring with it new
concerns among healthcare professionals about protecting
patients’ rights of confi-
dentiality, privacy, and autonomy. Systematic and flexible
ethical decision-making
abilities will be essential for all healthcare professionals.
Notably, the concept of nonmaleficence (“do no harm”) will be
broadened to
include those individuals and groups whom one may never see
in person, but with
whom one will enter into a professional relationship of trust and
care. Mack (2000)
82 ChapTEr 5 Ethical Applications of Informatics
rESEarCh BrIEF
Using an online survey of 1,227 randomly selected respondents,
Bodkin and
Miaoulis (2007) sought to describe the characteristics of
information seekers on
e-health websites, the types of information they seek, and their

perceptions of the
quality and ethics of the websites. Of the respondents, 74% had
sought health in-
formation on the Web, with women accounting for 55.8% of the
health informa-
tion seekers. A total of 50% of the seekers were between 35 and
54 years of age.
Nearly two thirds of the users began their searches using a
general search engine
rather than a health-specific site, unless they were seeking
information related to
symptoms or diseases. Top reasons for seeking information
were related to dis-
eases or symptoms of medical conditions, medication
information, health news,
health insurance, locating a doctor, and Medicare or Medicaid
information. The
level of education of information seekers was related to the
ratings of website
quality, in that more educated seekers found health information
websites more
understandable, but were more likely to perceive bias in the
website information.
The researchers also found that the ethical codes for e-health
websites seem to be

increasing consumers’ trust in the safety and quality of
information found on the
Web, but that most consumers are not comfortable purchasing
health products
or services online.
The full article appears in Bodkin, C., & Miaoulis, G. (2007).
eHealth information quality and
ethics issues: An exploratory study of consumer perceptions.
International Journal of Pharmaceuti-
cal and Healthcare Marketing, 1(1), 27–42. Retrieved from
ABI/INFORM Global (Document ID:
1515583081).
9781284122688_CH05.indd 82 16/12/16 5:52 PM
practices are sometimes more harmful than beneficial). A case
in point is the
long-standing practice of instilling endotracheal tubes with
normal saline before
suctioning (O’Neal, Grap, Thompson, & Dudley, 2001). Based
on the evidence
gathered through several studies, the potentially deleterious
effects of this practice
have become widely recognized. Conceivably, a meta-analysis

approach to clinical
studies will be expedited by convergence of large clinical data
repositories across
care settings, thereby making available to practitioners the
collective contribu-
tions of health professionals and longitudinal outcomes for
individuals, families,
and populations.
Nurses need to be engaged in the design of CIS tools that
support access to and
the generation of nursing knowledge. As we have emphasized,
the adoption of clini-
cal data standards is of particular importance to the future
design of CIS tools. We
are also beginning to see the development and use of expert
systems that implement
knowledge automatically without human intervention. For
example, an insulin pump
that senses the patient’s blood glucose level and administers
insulin based on those
data is a form of expert system. The expert system differs from
decision support tools
in that the decision support tools require the human to act on
the information pro-

vided, whereas the expert system intervenes automatically based
on an algorithm that
directs the intervention. Consider that as CISs are widely
implemented, as standards
for nursing documentation and reporting are adopted, and as
healthcare IT solutions
continue to evolve, the synthesis of findings from a variety of
methods and world-
views becomes much more feasible.
BOX 6-3 CaSE STuDy: CaSTINg TO ThE FuTurE
In the year 2025, nursing practice enabled by technology has
created a profes-
sional culture of reflection, critical inquiry, and
interprofessional collaboration.
Nurses use technology at the point of care in all clinical settings
(e.g., primary
care, acute care, community, and long-term care) to inform their
clinical deci-
sions and effect the best possible outcomes for their clients.
Information is gath-
ered and retrieved via human–technology biometric interfaces
including voice,
visual, sensory, gustatory, and auditory interfaces, which

continuously monitor
physiologic parameters for potentially harmful imbalances.
Longitudinal records
are maintained for all citizens from their initial prenatal
assessment to death;
all lifelong records are aggregated into the knowledge bases of
expert systems.
These systems provide the basis of the artificial intelligence
being embedded in
emerging technologies. Smart technologies and invisible
computing are ubiqui-
tous in all sectors where care is delivered. Clients and families
are empowered
to review and contribute actively to their record of health and
wellness. Invasive
diagnostic techniques are obsolete, nanotechnology therapeutics
are the norm,
and robotics supplement or replace much of the traditional work
of all health
professions. Nurses provide expertise to citizens to help them
effectively manage
their health and wellness life plans, and navigate access to
appropriate informa-
tion and services.

122 ChaPEr 6 History and Evolution of Nursing Informatics
9781284122688_CH06.indd 122 16/12/16 5:56 PM
The Future
The future landscape is yet to be fully understood, as
technology continues to evolve
with a rapidity and unfolding that is rich with promise and
potential peril. Box 6-3
helps us to imagine what future practice might entail. It is
anticipated that computing
power will be capable of aggregating and transforming
additional multidimensional
data and information sources (e.g., historical, multisensory,
experiential, and genetic
sources) into CIS. With the availability of such rich
repositories, further opportunities
will open up to enhance the training of health professionals,
advance the design and
application of CDSs, deliver care that is informed by the most
current evidence, and
engage with individuals and families in ways yet unimagined.
The basic education of all health professions will evolve over
the next decade to

incorporate core informatics competencies. In general, the
clinical care environments
will be connected, and information will be integrated across
disciplines to the benefit
of care providers and citizens alike. The future of health care
will be highly dependent
on the use of CISs and CDSs to achieve the global aspiration of
safer, quality care for
all citizens.
The ideal is a nursing practice that has wholly integrated
informatics and nursing
education and that is driven by the use of information and
knowledge from a myriad
of sources, creating practitioners whose way of being is
grounded in informatics.
Nursing research is dynamic and an enterprise in which all
nurses are engaged by
virtue of their use of technologies to gather and analyze
findings that inform specific
clinical situations. In every practice setting, the contributions of
nurses to health and
well-being of citizens will be highly respected and parallel, if
not exceed, the preemi-
nence granted physicians.

Summary
In this chapter, we have traced the development of informatics
as a specialty, defined
nursing informatics, and explored the DIKW paradigm central
to informatics. We
also explored the need for and the development of standardized
terminologies to
capture and codify the work of nursing and how informatics
supports the knowledge
work of nursing. This chapter advanced the view that every
nurse’s practice will make
contributions to new nursing knowledge in dynamically
interactive CIS environ-
ments. The core concepts associated with informatics will
become embedded in the
practice of every nurse, whether administrator, researcher,
educator, or practitioner.
Informatics will be prominent in the knowledge work of nurses,
yet it will be a sub-
tlety because of its eventual fulsome integration with clinical
care processes. Clinical
care will be substantially supported by the capacity and promise
of technology today
and tomorrow.

Most importantly, readers need to contemplate a future without
being limited by
the world of practice as it is known today. Information
technology is not a panacea
for all of the challenges found in health care, but it will provide
the nursing profes-
sion with an unprecedented capacity to generate and disseminate
new knowledge at
rapid speed. Realizing these possibilities necessitates that all
nurses understand and
leverage the informatician within and contribute to the future.
Summary 123
9781284122688_CH06.indd 123 16/12/16 5:56 PM
This text is designed to include the necessary content to prepare
nurses for prac-
tice in the ever-changing and technology-laden healthcare
environments. Informatics
competence has been recognized as necessary in order to
enhance clinical decision
making and improve patient care for many years. This is
evidenced by Goossen

(2000), who reflected on the need for research in this area and
believed that the
focus of nursing informatics research should be on the
structuring and processing of
patient information and the ways that these endeavors inform
nursing decision mak-
ing in clinical practice. The increased use of technology to
enhance nursing practice,
nursing education, and nursing research will open new avenues
for acquiring, pro-
cessing, generating, and disseminating knowledge.
In the future, nursing research will make significant
contributions to the devel-
opment of nursing science. Technologies and translational
research will abound,
and clinical practices will continue to be evidence based,
thereby improving patient
outcomes and decreasing safety concerns. Schools of nursing
will embrace nursing
science as they strive to meet the needs of changing student
populations and the
increasing complexity of healthcare environments.
Summary

Nursing science influences all areas of nursing practice. This
chapter provided an
overview of nursing science and considered how nursing science
relates to typical
nursing practice roles, nursing education, informatics, and
nursing research. The
Foundation of Knowledge model was introduced as the
organizing conceptual
framework for this text. Finally, the relationship of nursing
science to nursing
informatics was discussed. In subsequent chapters the reader
will learn more
about how nursing informatics supports nurses in their many
and varied roles.
In an ideal world, nurses would embrace nursing science as
knowledge users,
knowledge managers, knowledge developers, knowledge
engineers, and knowl-
edge workers.
ThOUGhT-prOVOKING QUeSTIONS
1. Imagine you are in a social situation and someone asks you,
“What does a nurse
do?” Think about how you will capture and convey the richness

that is nursing
science in your answer.
2. Choose a clinical scenario from your recent experience and
analyze it using the
Foundation of Knowledge model. How did you acquire
knowledge? How did
you process knowledge? How did you generate knowledge? How
did you dis-
seminate knowledge? How did you use feedback, and what was
the effect of the
feedback on the foundation of your knowledge?
18 ChapTer 1 Nursing Science and the Foundation of
Knowledge
9781284122688_CH01.indd 18 15/12/16 8:25 PM
Research Briefs These summaries
encourage students to access current
research in the field.
Thought-Provoking Questions Students
can work on these critical thinking assign-
ments individually or in a group. In addition,

students can delve deeper into concepts by
completing these exercises online.
Case Studies Case studies encourage
active learning and promote critical think-
ing skills. Students can ask questions,
analyze situations, and solve problems in
a real-world context.
FOURTH EDITION
Dee McGonigle, PhD, RN, CNE, FAAN, ANEF
Director, Virtual Learning Experiences (VLE) and Professor
Graduate Program, Chamberlain College of Nursing
Member, Informatics and Technology Expert Panel (ITEP) for
the
American Academy of Nursing
Kathleen Mastrian, PhD, RN
Associate Professor and Program Coordinator for Nursing
Pennsylvania State University, Shenango

Sr. Managing Editor, Online Journal of Nursing Informatics
(OJNI)
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vii
Preface xvi
Acknowledgments xix

Contributors xxi
SECTION I: BUILDING BLOCKS OF NURSING
INFORMATICS 1
1 Nursing Science and the Foundation of Knowledge 7
Dee McGonigle and Kathleen Mastrian
Introduction 7
Quality and Safety Education for Nurses 16
Summary 18
References 19
2 Introduction to Information, Information Science, and
Information Systems 21
Kathleen Mastrian and Dee McGonigle
Introduction 21
Information 22
Information Science 25
Information Processing 26
Information Science and the Foundation of Knowledge 27
Introduction to Information Systems 28
Summary 32
References 33
3 Computer Science and the Foundation of Knowledge Model

35
Dee McGonigle, Kathleen Mastrian, and June Kaminski
Introduction 35
The Computer as a Tool for Managing Information and
Generating Knowledge 36
Components 38
What Is the Relationship of Computer Science to Knowledge?
53
How Does the Computer Support Collaboration and Information
Exchange? 54
Cloud Computing 57
Looking to the Future 59
Summary 61
Working Wisdom 61
Application Scenario 62
References 62
Contents
viii
4 Introduction to Cognitive Science and Cognitive Informatics
65

Introduction 65
Cognitive Science 65
Sources of Knowledge 68
Nature of Knowledge 69
How Knowledge and Wisdom Are Used in Decision Making 69
Cognitive Informatics 70
Cognitive Informatics and Nursing Practice 71
What Is AI? 72
Summary 73
References 74
5 Ethical Applications of Informatics 77
Dee McGonigle, Kathleen Mastrian, and Nedra Farcus
Introduction 77
Ethics 78
Bioethics 79
Ethical Issues and Social Media 80
Ethical Dilemmas and Morals 81
Ethical Decision Making 82
Theoretical Approaches to Healthcare Ethics 83
Applying Ethics to Informatics 86
Case Analysis Demonstration 91
New Frontiers in Ethical Issues 95
Summary 96

References 97
SECTION II: PERSPECTIVES ON NURSING INFORMATICS
99
6 History and Evolution of Nursing Informatics 105
Introduction 105
The Evolution of a Specialty 106
What Is Nursing Informatics? 108
The DIKW Paradigm 109
Capturing and Codifying the Work of Nursing 112
The Nurse as a Knowledge Worker 117
The Future 123
Summary 123
References 124
7 Nursing Informatics as a Specialty 127
Dee McGonigle, Kathleen Mastrian, Julie A. Kenney, and Ida
Androwich
Introduction 127
Nursing Contributions to Healthcare Informatics 127
Contents ix

Scope and Standards 128
Nursing Informatics Roles 129
Specialty Education and Certification 131
Nursing Informatics Competencies 133
Rewards of NI Practice 138
NI Organizations and Journals 138
The Future of Nursing Informatics 139
Summary 141
References 142
8 Legislative Aspects of Nursing Informatics: HITECH and
HIPAA 145
Kathleen M. Gialanella, Kathleen Mastrian, and Dee McGonigle
Introduction 145
HIPAA Came First 145
Overview of the HITECH Act 148
How a National HIT Infrastructure Is Being Developed 153
How the HITECH Act Changed HIPAA 154
Implications for Nursing Practice 161
Future Regulations 165
Summary 165
References 166

SECTION III: NURSING INFORMATICS ADMINISTRATIVE
APPLICATIONS: PRECARE AND CARE SUPPORT 169
9 Systems Development Life Cycle: Nursing Informatics
and Organizational Decision Making 175
Introduction 175
Waterfall Model 178
Rapid Prototyping or Rapid Application Development 180
Object-Oriented Systems Development 181
Dynamic System Development Method 181
Computer-Aided Software Engineering Tools 184
Open Source Software and Free/Open Source Software 184
Interoperability 185
Summary 186
References 187
10 Administrative Information Systems 189
Marianela Zytkowski, Susan Paschke, Kathleen Mastrian, and
Dee McGonigle
Introduction 189
Types of Healthcare Organization Information Systems 190
Communication Systems 190
Core Business Systems 191
Order Entry Systems 193

Patient Care Support Systems 194
x Contents
Interoperability 195
Aggregating Patient and Organizational Data 197
Department Collaboration and Exchange of Knowledge and
Information 202
Summary 203
References 204
11 The Human–Technology Interface 207
Dee McGonigle, Kathleen Mastrian, and Judith A. Effken
Introduction 207
The Human–Technology Interface 208
The Human–Technology Interface Problem 211
Improving the Human–Technology Interface 212
A Framework for Evaluation 221
Future of the Human–Technology Interface 221
Summary 223
References 224
12 Electronic Security 229

Lisa Reeves Bertin, Kathleen Mastrian, and Dee McGonigle
Introduction 229
Securing Network Information 229
Authentication of Users 231
Threats to Security 232
Security Tools 237
Offsite Use of Portable Devices 238
Summary 241
References 242
13 Workflow and Beyond Meaningful Use 245
Dee McGonigle, Kathleen Mastrian, and Denise Hammel-Jones
Introduction 245
Workflow Analysis Purpose 245
Workflow and Technology 249
Workflow Analysis and Informatics Practice 251
Informatics as a Change Agent 256
Measuring the Results 258
Future Directions 259
Summary 260
References 261
SECTION IV: NURSING INFORMATICS PRACTICE
APPLICATIONS:
CARE DELIVERY 263

14 The Electronic Health Record and Clinical Informatics 267
Emily B. Barey, Kathleen Mastrian, and Dee McGonigle
Introduction 267
Setting the Stage 268
Contents xi
Components of Electronic Health Records 269
Advantages of Electronic Health Records 274
Standardized Terminology and the EHR 278
Ownership of Electronic Health Records 280
Flexibility and Expandability 283
Accountable Care Organizations and the EHR 285
The Future 285
Summary 287
References 287
15 Informatics Tools to Promote Patient Safety and Quality
Outcomes 293
Introduction 293
What Is a Culture of Safety? 294

Strategies for Developing a Safety Culture 296
Informatics Technologies for Patient Safety 301
Role of the Nurse Informaticist 313
Summary 315
References 317
16 Patient Engagement and Connected Health 323
Introduction 323
Consumer Demand for Information 324
Health Literacy and Health Initiatives 325
Healthcare Organization Approaches to Engagement 327
Promoting Health Literacy in School-Aged Children 329
Supporting Use of the Internet for Health Education 330
Future Directions for Engaging Patients 335
Summary 337
References 338
17 Using Informatics to Promote Community/Population Health
341
Dee McGonigle, Kathleen Mastrian, Margaret Ross Kraft, and
Ida Androwich
Introduction 341
Core Public Health Functions 343
Community Health Risk Assessment: Tools for Acquiring

Knowledge 345
Processing Knowledge and Information to Support
Epidemiology
and Monitoring Disease Outbreaks 347
Applying Knowledge to Health Disaster Planning and
Preparation 349
Informatics Tools to Support Communication and Dissemination
350
Using Feedback to Improve Responses and Promote Readiness
351
Summary 353
References 355
xii Contents
18 Telenursing and Remote Access Telehealth 359
Original contribution by Audrey Kinsella, Kathleen Albright,
Sheldon Prial,
and Schuyler F. Hoss; revised by Kathleen Mastrian and Dee
McGonigle
Introduction 359
The Foundation of Knowledge Model and Home Telehealth 359
Nursing Aspects of Telehealth 361

History of Telehealth 362
Driving Forces for Telehealth 363
Telehealth Care 366
Telenursing 370
Telehealth Patient Populations 372
Tools of Home Telehealth 375
Home Telehealth Software 378
Home Telehealth Practice and Protocols 380
Legal, Ethical, and Regulatory Issues 381
The Patient’s Role in Telehealth 382
Telehealth Research 383
Evolving Telehealth Models 385
Parting Thoughts for the Future and a View Toward What the
Future Holds 386
Summary 387
References 388
SECTION V: EDUCATION APPLICATIONS OF NURSING
INFORMATICS 393
19 Nursing Informatics and Nursing Education 397
Heather E. McKinney, Sylvia DeSantis, Kathleen Mastrian, and
Dee McGonigle
Introduction: Nursing Education and the Foundation of
Knowledge Model 397

Knowledge Acquisition and Sharing 398
Evolution of Learning Management Systems 398
Delivery Modalities 400
Technology Tools Supporting Education 405
Internet-Based Tools 413
Promoting Active and Collaborative Learning 420
Knowledge Dissemination and Sharing 423
Exploring Information Fair Use and Copyright Restrictions 426
The Future 427
Summary 428
References 429
20 Simulation, Game Mechanics, and Virtual Worlds in
Nursing Education 433
Dee McGonigle, Kathleen Mastrian, Brett Bixler, and Nickolaus
Miehl
Introduction 433
Simulation in Nursing Informatics Education 434
Nursing Informatics Competencies in Nursing Education 436
A Case for Simulation in Nursing Informatics Education and
Contents xiii

Incorporating EHRs into the Learning Environment 441
Challenges and Opportunities 445
The Future of Simulation in Nursing Informatics Education 445
Game Mechanics and Virtual World Simulation for Nursing
Education 446
Game Mechanics and Educational Games 448
Virtual Worlds in Education 450
Choosing Among Simulations, Educational Games, and Virtual
Worlds 451
The Future of Simulations, Games, and Virtual Worlds in
Summary 453
References 454
SECTION VI: RESEARCH APPLICATIONS OF NURSING
INFORMATICS 459
21 Nursing Research: Data Collection, Processing, and
Analysis 463
Heather E. McKinney, Sylvia DeSantis, Kathleen Mastrian, and
Dee McGonigle
Introduction: Nursing Research and the Foundation of
Knowledge Model 463
Knowledge Generation Through Nursing Research 464

Acquiring Previously Gained Knowledge Through Internet and
Library Holdings 466
Fair Use of Information and Sharing 468
Informatics Tools for Collecting Data and Storage of
Information 469
Tools for Processing Data and Data Analysis 471
The Future 473
Summary 473
References 474
22 Data Mining as a Research Tool 477
Introduction: Big Data, Data Mining, and Knowledge Discovery
477
KDD and Research 481
Data Mining Concepts 482
Data Mining Techniques 483
Data Mining Models 486
Benefits of KDD 489
Data Mining and Electronic Health Records 490
Ethics of Data Mining 491
Summary 491
References 492
23 Translational Research: Generating Evidence for Practice

495
Jennifer Bredemeyer, Ida Androwich, Dee McGonigle, and
Kathleen Mastrian
Introduction 495
Clarification of Terms 495
History of Evidence-Based Practice 498
Evidence 498
Bridging the Gap Between Research and Practice 499
Barriers to and Facilitators of Evidence-Based Practice 500
The Role of Informatics 500
xiv Contents
Developing EBP Guidelines 503
Meta-Analysis and Generation of Knowledge 504
The Future 505
Summary 506
References 507
24 Bioinformatics, Biomedical Informatics, and Computational
Biology 511
Introduction 511

Bioinformatics, Biomedical Informatics, and Computational
Biology Defined 511
Why Are Bioinformatics and Biomedical Informatics So
Important? 514
What Does the Future Hold? 516
Summary 518
References 519
SECTION VII: IMAGINING THE FUTURE OF NURSING
INFORMATICS 521
25 The Art of Caring in Technology-Laden Environments 525
Introduction 525
Caring Theories 526
Presence 529
Strategies for Enhancing Caring Presence 530
Reflective Practice 533
Summary 534
References 535
26 Nursing Informatics and the Foundation of Knowledge 537
Introduction 537
Foundation of Knowledge Revisited 537

The Nature of Knowledge 539
Knowledge Use in Practice 541
Characteristics of Knowledge Workers 544
Knowledge Management in Organizations 545
Managing Knowledge Across Disciplines 547
The Learning Healthcare System 548
Summary 550
References 551
Abbreviations 553
Glossary 556
Index 586
Contents xv
Preface
The idea for this text originated with the development of
nursing informatics (NI) classes, the publication
of articles related to technology-based education, and the
creation of the Online Journal of Nursing Infor-
matics (OJNI), which Dee McGonigle cofounded with Renee
Eggers. Like most nurse informaticists, we

fell into the specialty; our love affair with technology and
gadgets and our willingness to be the first to try
new things helped to hook us into the specialty of informatics.
The rapid evolution of technology and its
transformation of the ways of nursing prompted us to try to
capture the essence of NI in a text.
As we were developing the first edition, we realized that we
could not possibly know all there is to
know about informatics and the way in which it supports
nursing practice, education, administration, and
research. We also knew that our faculty roles constrained our
opportunities for exposure to changes in this
rapidly evolving field. Therefore, we developed a tentative
outline and a working model of the theoretical
framework for the text and invited participation from
informatics experts and specialists around the world.
We were pleased with the enthusiastic responses we received
from some of those invited contributors and a
few volunteers who heard about the text and asked to participate
in their particular area of expertise.
In the second edition, we invited the original contributors to
revise and update their chapters. Not
everyone chose to participate in the second edition, so we

revised several of the chapters using the original
work as a springboard. The revisions to the text were guided by
the contributors’ growing informatics
expertise and the reviews provided by textbook adopters. In the
revisions, we sought to do the following:
• Expand the audience focus to include nursing students from
BS through DNP programs as well as
nurses thrust into informatics roles in clinical agencies.
• Include, whenever possible, an attention-grabbing case
scenario as an introduction or an illustrative
case scenario demonstrating why the topic is important.
• Include important research findings related to the topic. Many
chapters have research briefs pre-
sented in text boxes to encourage the reader to access current
research.
• Focus on cutting-edge innovations, meaningful use, and
patient safety as appropriate to each topic.
• Include a paragraph describing what the future holds for each
topic.
New chapters that were added to the second edition included

those focusing on technology and patient
safety, system development life cycle, workflow analysis,
gaming, simulation, and bioinformatics.
In the third edition, we reviewed and updated all of the
chapters, reordered some chapters for better
content flow, eliminated duplicated content, split the education
and research content into two sections,
integrated social media content, and added two new chapters:
Data Mining as a Research Tool and The
Art of Caring in Technology-Laden Environments.
In this fourth edition, we reviewed and updated all of the
chapters based on technological advance-
ments and changes to the healthcare arena, including
reimbursement mechanisms for services. We have
pared this edition down to 26 chapters from the previous
edition’s 29; one chapter each was deleted from
Sections II, V, and VII. Section I includes updates to the same
five chapters on the building blocks of nurs-
ing informatics, with extensive changes to Chapter 3, Computer
Science and the Foundation of Knowledge
Model. To improve flow, we combined content. In Section II,
the previous four chapters were narrowed
to three. New Chapters 6, History and Evolution of Nursing

Informatics and 7, Nursing Informatics as
xvi
a Specialty, were developed and appropriate material from
previous Chapters 6, 7, and 8 were assimi-
lated. This section ends with an updated Chapter 8, Legislative
Aspects of Nursing Informatics: HITECH
and HIPAA (formerly Chapter 9). Section III contains the same
five chapters, although all were updated
and Chapter 13, Workflow and Beyond Meaningful Use
(formerly Chapter 14) now reflects the payment
models and reimbursement issues that we are adjusting to after
meaningful use has gone away. Section IV
contains the same five chapters with updated content and some
name changes to reflect the current status
of informatics and healthcare. Chapter 15 was renamed to
Informatics Tools to Promote Patient Safety
and Quality Outcomes, and Chapter 16 has been changed to
Patient Engagement and Connected Health.
Section V went from three chapters to two chapters: Chapter 19
(formerly Chapter 20) was updated, while
the new Chapter 20, Simulation, Game Mechanics, and Virtual

Worlds in Nursing Education, had content
from former Chapters 21 and 22 integrated during its
development. Section VI was renamed to Research
Applications of Nursing Informatics. It still has the same four
chapters, which have been updated, but the
first chapter in this section, 21, was renamed to reflect nursing
research; its new name is Nursing Research:
Data Collection, Processing, and Analysis. Section VII went
from three chapters to two chapters. Because
emerging technologies are discussed throughout the text, the
chapter focusing specifically on that was
removed. The two chapters that remain are Chapter 25, The Art
of Caring in Technology-Laden Environ-
ments, and the new Chapter 26, Nursing Informatics and
Knowledge Management. In addition, the ancil-
lary materials have been updated and enhanced to include
competency-based self-assessments and mapping
the content to the current NI standards.
We believe that this text provides a comprehensive elucidation
of this exciting field. Its theoretical under-
pinning is the Foundation of Knowledge model. This model is
introduced in its entirety in the first chapter
(Nursing Science and the Foundation of Knowledge), which
discusses nursing science and its relationship

to NI. We believe that humans are organic information systems
that are constantly acquiring, processing, and
generating information or knowledge in both their professional
and personal lives. It is their high degree of
knowledge that characterizes humans as extremely intelligent,
organic machines. Individuals have the ability
to manage knowledge—an ability that is learned and honed from
birth. We make our way through life inter-
acting with our environment and being inundated with
information and knowledge. We experience our envi-
ronment and learn by acquiring, processing, generating, and
disseminating knowledge. As we interact in our
environment, we acquire knowledge that we must process. This
processing effort causes us to redefine and re-
structure our knowledge base and generate new knowledge. We
then share (disseminate) this new knowledge
and receive feedback from others. The dissemination and
feedback initiate this cycle of knowledge over again,
as we acquire, process, generate, and disseminate the knowledge
gained from sharing and re-exploring our
own knowledge base. As others respond to our knowledge
dissemination and we acquire new knowledge, we
engage in rethinking and reflecting on our knowledge,
processing, generating, and then disseminating anew.

The purpose of this text is to provide a set of practical and
powerful tools to ensure that the reader
gains an understanding of NI and moves from information
through knowledge to wisdom. Defining the
demands of nurses and providing tools to help them survive and
succeed in the Knowledge Era remains
a major challenge. Exposing nursing students and nurses to the
principles and tools used in NI helps to
prepare them to meet the challenge of practicing nursing in the
Knowledge Era while striving to improve
patient care at all levels.
The text provides a comprehensive framework that embraces
knowledge so that readers can develop
their knowledge repositories and the wisdom necessary to act on
and apply that knowledge. The text is
divided into seven sections.
• Section I, Building Blocks of Nursing Informatics, covers the
building blocks of NI: nursing science,
information science, computer science, cognitive science, and
the ethical management of information.
• Section II, Perspectives on Nursing Informatics, provides
readers with a look at various viewpoints

on NI and NI practice as described by experts in the field.
Preface xvii
• Section III, Nursing Informatics Administrative Applications:
Precare and Care Support, covers
important functions of administrative applications of NI.
• Section IV, Nursing Informatics Practice Applications: Care
Delivery, covers healthcare delivery
applications including electronic health records (EHRs), clinical
information systems, telehealth,
patient safety, patient and community education, and care
management.
• Section V, Education Applications of Nursing Informatics,
presents subject matter on how informat-
ics supports nursing education.
• Section VI, Research Applications of Nursing Informatics,
covers informatics tools to support
nursing research, including data mining and bioinformatics.

• Section VII, Imagining the Future of Nursing Informatics,
focuses on the future of NI, emphasizes
the need to preserve caring functions in technology-laden
environments, and reviews the relationship
of nursing informatics to organizational knowledge
management.
The introduction to each section explains the relationship
between the content of that section and the
Foundation of Knowledge model. This text places the material
within the context of knowledge acqui-
sition, processing, generation, and dissemination. It serves both
nursing students (BS to DNP/PhD) and
professionals who need to understand, use, and evaluate NI
knowledge. As nursing professors, our major
responsibility is to prepare the practitioners and leaders in the
field. Because NI permeates the entire scope
of nursing (practice, administration, education, and research),
nursing education curricula must include NI.
Our primary objective is to develop the most comprehensive and
user-friendly NI text on the market to
prepare nurses for current and future practice challenges. In
particular, this text provides a solid ground-
work from which to integrate NI into practice, education,
administration, and research.

Goals of this text are as follows:
• Impart core NI principles that should be familiar to every
nurse and nursing student
• Help the reader understand knowledge and how it is acquired,
processed, generated, and
disseminated
• Explore the changing role of NI professionals
• Demonstrate the value of the NI discipline as an attractive
field of specialization
Meeting these goals will help nurses and nursing students
understand and use fundamental NI princi-
ples so that they efficiently and effectively function as current
and future nursing professionals to enhance
the nursing profession and improve the quality of health care.
The overall vision, framework, and peda-
gogy of this text offer benefits to readers by highlighting
established principles while drawing out new ones
that continue to emerge as nursing and technology evolve.
xviii Preface

Acknowledgments
We are deeply grateful to the contributors who provided this
text with a richness and diversity of content
that we could not have captured alone. Joan Humphrey provided
social media content integrated throughout
the text. We especially wish to acknowledge the superior work
of Alicia Mastrian, graphic designer of the
Foundation of Knowledge model, which serves as the
theoretical framework on which this text is anchored.
We could never have completed this project without the
dedicated and patient efforts of the Jones & Bartlett
Learning staff, especially Amanda Martin, Emma Huggard, and
Christina Freitas, all of whom fielded our
questions and concerns in a very professional, respectful, and
timely manner.
Dee acknowledges the undying love, support, patience, and
continued encouragement of her best friend
and husband, Craig, and her son, Craig, who has made her so
very proud. She sincerely thanks her cousins
Camille, Glenn, Mary Jane, and Sonny, and her dear friends for
their support and encouragement, espe-

cially Renee.
Kathy acknowledges the loving support of her family: husband
Chip; children Ben and Alicia; sisters
Carol and Sue; and parents Robert and Rosalie Garver. She
dedicates her work on this edition to her dad,
Robert, who died September 17, 2016. Kathy also acknowledges
those friends who understand the impor-
tance of validation, especially Katie, Lisa, Kathy, Maureen,
Anne, Barbara, and Sally.
xix
This text provides an overview of nursing informatics from
the perspective of diverse experts in the field, with a focus
on nursing informatics and the Foundation of Knowledge
model. We want our readers and students to focus on the
relationship of knowledge to informatics and to embrace
and maintain the caring functions of nursing—messages
all too often lost in the romance with technology. We hope
you enjoy the text!
Authors’ Note

xx
Contributors
Ida Androwich, PhD, RN, BC, FAAN
Loyola University Chicago
School of Nursing
Maywood, IL
Emily Barey, MSN, RN
Director of Nursing Informatics
Epic Systems Corporation
Madison, WI
Lisa Reeves Bertin, BS, EMBA
Pennsylvania State University
Sharon, PA
Brett Bixler, PhD
University Park, PA

Jennifer Bredemeyer, RN
School of Nursing
Skokie, IL
Steven Brewer, PhD
Assistant Professor, Administration of Justice
Sharon, PA
Sylvia M. DeSantis, MA
University Park, PA
Judith Effken, PhD, RN, FACMI
University of Arizona
College of Nursing
Tucson, AZ
Nedra Farcus, MSN, RN
Retired from Pennsylvania State University, Altoona
Altoona, PA
Kathleen M. Gialanella, JD, RN, LLM
Law Offices

Westfield, NJ
Associate Adjunct Professor
Teachers College, Columbia University
New York, NY
Adjunct Professor
Seton Hall University, College of Nursing &
School of Law
South Orange & Newark, NJ
Denise Hammel-Jones, MSN, RN-BC, CLSSBB
Greencastle Associates Consulting
Malvern, PA
Nicholas Hardiker, PhD, RN
Senior Research Fellow
University of Salford
School of Nursing & Midwifery
Salford, UK
Glenn Johnson, MLS
University Park, PA
June Kaminski, MSN, RN

Kwantlen University College
Surrey, British Columbia, Canada
Julie Kenney, MSN, RNC-OB
Clinical Analyst
Advocate Health Care
Oak Brook, IL
Margaret Ross Kraft, PhD, RN
School of Nursing
Maywood, IL
xxi
Wendy L. Mahan, PhD, CRC, LPC
University Park, PA
Heather McKinney, PhD
University Park, PA

Nickolaus Miehl, MSN, RN
Oregon Health Sciences University
Monmouth, OR
Lynn M. Nagle, PhD, RN
Assistant Professor
University of Toronto
Toronto, Ontario, Canada
Ramona Nelson, PhD, RN-BC, FAAN, ANEF
Professor Emerita, Slippery Rock University
President, Ramona Nelson Consulting
Pittsburgh, PA
Nancy Staggers, PhD, RN, FAAN
Professor, Informatics
University of Maryland
Baltimore, MD
Jeff Swain
Instructional Designer
University Park, PA
Denise D. Tyler, MSN/MBA, RN-BC

Implementation Specialist
Healthcare Provider, Consulting
ACS, a Xerox Company
Dearborn, MI
The Editors also acknowledge the work of the following first
edition contributors (original contributions edited by
McGonigle and Mastrian for second edition):
Kathleen Albright, BA, RN
Strategic Account Manager at GE Healthcare
Philadelphia, PA
Schuyler F. Hoss, BA
Northwest Healthcare Management
Vancouver, WA
Audrey Kinsella, MA, MS
Information for Tomorrow
Telehealth Planning Services
Asheville, NC
Peter J. Murray, PhD, RN, FBCS
Coachman’s Cottage
Nocton, Lincoln, UK

Susan M. Paschke, MSN, RN
The Cleveland Clinic
Cleveland, OH
Sheldon Prial, RPH, BS Pharmacy
Sheldon Prial Consultance
Melbourne, FL
Jackie Ritzko
Hazelton, PA
Marianela Zytkowsi, MSN, RN
The Cleveland Clinic
Cleveland, OH
xxii Contributors
section i
Building Blocks of
Nursing Informatics

Chapter 1 Nursing Science and the Foundation of Knowledge
Chapter 2 Introduction to Information, Information Science,
and Information Systems
Chapter 3 Computer Science and the Foundation of Knowledge
Model
Chapter 4 Introduction to Cognitive Science and Cognitive
Informatics
Chapter 5 Ethical Applications of Informatics
Nursing professionals are information-dependent knowledge
workers. As health
care continues to evolve in an increasingly competitive
information marketplace,
professionals—that is, the knowledge workers—must be well
prepared to make
significant contributions by harnessing appropriate and timely
information. Nurs-
ing informatics (NI), a product of the scientific synthesis of
information in nursing,

Evolving Role of Nursing Informatics Specialists in Connected Health

Evolving Role of Nursing Informatics Specialists in Connected Health

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