Role of informatics nurse

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

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“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).

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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

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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 informatics specialists

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

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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

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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 informatics specialists

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

 

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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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