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CHALLENGES IN NURSING INFORMATICS

by Crystal Dee Fuller RN, DNP, CRNP
Faculty of Central Alabama Community College
CoosaValley Schoolof Nursing

 
Introduction

  The writer recalls the immergence of alternative methods of nursing documentation in the mid-to-late 1980s, which were designed to become more time effective methods of charting. Use of flow sheets, check sheets, and eventually computerized charting was the response to nurses’ long hours spent on documenting the events of the shift. Today, the use of technology to document patient data is at the forefront of health care discussions. Not only is the use of technology discussed as being more efficient in the delivery of healthcare, but also as a means of improving patient outcomes. As the use of technology explodes into the health care industry, its effects have the potential to become destructive elements to the nursing profession. This paper will discuss the evolution of nursing documentation, the immergence of health information technology, and the challenges it creates for the nursing profession.

  Review of literature reveals much discussion on the concepts of health information and the technology used to manage this type of information i.e. health information technology. The U.S. Department of Health and Human Services (2009) describes health information technology as comprehensive management of medical information and the exchange of this information between health care consumers and providers. Given that the Healthcare Information and Management Systems Society (HIMSS) Nursing Informatics Awareness Task Force (2007) reports that an estimated 50% of a nurse’s time in spent on documentation, one could reason that nursing documentation is a very important process of nursing practice and an integral aspect of nursing intervention.
 

Evolution of Nursing Documentation

  Historically, nursing documentation has been a hand- written account of the nurse’s fulfillment of the professional and legal duty of care. This documentation process has evolved to provide effective communication between health care professionals, a plan of patient care for the patient, an avenue for compensation from health care insurances, analysis of health care, a source for education and research, and the legal document of the patient’s medical position. Today, the nursing documentation process is undergoing revolutionary transformation. This is, in part, due to the vast amounts of medical-related knowledge generated. Kaminiski (2005) reports that information is doubling every five years, if not tripling. In addition, there is increasing pressure for healthcare systems to improve efficiency and effectiveness. The high rate of medical errors and rising healthcare costs are now the driving forces behind the transformation of information management, and affects not only nursing, but all healthcare professionals.

Background

  The United States healthcare system is moving assertively toward the widespread use of information technology (IT).Under the direction of President Bush, the position of National Coordinator for Health Information Technology was created with the goal of a nationwide adoption of electronic medical records within 10 years (Stein and Deese, 2004). In the 2008 election, both candidates called for implementation of electronic health records as a means of decreasing medical errors and curtailing healthcare costs. The Obama administration has recently requested additional budgeted funds of $19 billion for the purpose of health information technology development (Mosquere, 2009). In the president’s address to the nation recently, he reaffirmed his plans to promote electronic health records has a means to improve healthcare costs. It is apparent that under the present administration, electronic health records will become a reality.

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