“Computers and Nursing” by Jeff Zipparo

Computers have helped nearly every industry, electronic based or not, to better serve themselves, and their clients;
largely through software programs that allow industries to streamline complex business-related data and that permit
better communication between employers, employees, and clients. Without a doubt, computers have a strong place in
our society and will continue to affect the way in which businesses conduct themselves, including the medical industry.

One example of computers in the medical field is bedside monitor devices. These computers are helping advance medical
care to a level of quality formerly unimaginable. Computers are, and will continue to allow nurses to access, record, and
monitor patient records, as well as, find in depth research related to their patient within seconds. This is a vast
improvement to the hours it may have taken in the past. “Because of this time reduction, nurses are able to have more
direct client care” (Ricketts, 2003).

The increase in direct patient care allows for a better nurse-patient relationship, thus letting the nurse truly affect the
wellbeing of the patient. A nurse acting in the educator role, and with a computer, will no longer be limited to
handwritten self-care directions or black and white sketches. Nurses will be able to access video clips, diagrams, and
detailed pictures to help the patient on the road to recovery. Furthermore, with the guidance of a nurse a patient will be
able to “access support groups, medical facilities, and health care providers,” thus “empowering clients to assume an
active role in their health care” (Ricketts, 2003).

Computers will also be able to help nurses on a personal level. There are a host of online courses that a nurse can take
which will allow better patient care, as well as, opening the door to new job opportunities and job advancements for the
nurse. Additionally, the internet allows nurses to search for careers around the world, and even research employers to
find the best possible match. The internet also allows nurses to keep in touch with each other through forums and news
groups. These online discussion areas “provide nurses with a method of exchanging immediate information and
discussing nurse-related issues with colleagues throughout the world.” (Ricketts, 2003).

The ultimate goal of the medical-computer relationship is to one day allow client records to be viewed by experts across
the world via the internet, and to have vital information immediately sent to the bedside nurse in order to provide the
best possible care to the client. However, moving from the “hard copy” age to the computer age does have risks. One
such risk is the hacking of client records, which poses a major risk to the privacy of patients. Another risk is the loss of
entire client data bases due to software viruses or hardware failure. Finally, in the event of large-scale power problems
the medical staff could be without pertinent patient information for extended periods of time, which would greatly hamper
patient care.

Nonetheless, I believe computers to be a necessary part of the medical community. From the simplest PDA program to
the most complex electronic surgical monitoring device, computers have found a niche in medicine that is only adding to
the success of medical procedures. As the computer raised generations slowly enter the medical field, the symbiotic
relationship between computers and professionals is one of incredible potential.

Major Historical Perspectives of Nursing and Computers

Computer technology emerged in nursing in response to the changing and developing technologies in the healthcare
industry and in nursing practice. The major historical perspectives of nursing and computers can be analyzed based on
the following themes:

 Six time periods (divided on time coverage prior to 1960s to post 2000)
 Four major nursing areas (nursing practice, administration, education and research)
 Standards initiatives (nursing practice, data, healthcare data standards)
 Significant landmark events (chart)
Six Time Periods

Six historical perspectives of nursing and computers are as follows:

Prior to 1960s -Simple Beginnings

The use of computers in both computer and medical industry grew on early 1950s. There were only few experts who
formed a cadre of pioneers that attempted to adapt computers to healthcare and nursing. During this time, the image of
nursing profession is undergoing major changes: improving nursing image, expansion of scope and complexity of nursing
practice and services and the increasing number of new nurses. Initially, computers were used in health care facilities for
basic business office transactions. Some examples are punch cards to store data and card readers for computer
programs, sorting and preparation of data for processing. They were linked together and operated by paper tape and
used teletypewriters to print their output. As computer technology advanced, healthcare technologies improved.

1960s -Issues and NI Researches

The use of computer technology in healthcare settings began to be questioned. Areas of debate are centered on the
application of computers and data that needs to be computerized. Nursing standards were reviewed and resources were
analyzed. Studies were conducted to assess computer technology and its effective utilization in the healthcare industry.
Nurses’ stations were considered as “hub” of information exchange.

The increasing number of healthcare facilities was paralleled to the advancement in computer technology. The
introduction of new computer technologies such as the Cathode Ray Tubes (CRT) added more dimensions to computer
systems providing more accessible and user-friendly machines.

Hospital Information Systems (HISs) were primarily developed to process financial transactions but few emerged to
document and process healthcare activities.

Computer vendors were beginning to penetrate the healthcare field but the progress was slow due to limitations in
technology, lack of standardization and diversity in paper-based patient records.

1970s -Giant Leap for NI

Nurses begin to recognize the value of the computer for their profession. Giant steps were taken in both nursing and
computer technology. Nurses assisted in the design of HISs and other environment that lead to the development of
forerunning software as bases of today’s systems. Computer applications for financial and management functions of
patient care systems were perceived as cost-saving technologies. Several states and large community health agencies in
the US developed and/or contracted for their own computer-based Management Information Systems (MISs) which
provide statistical and financial information required local government and federal agencies for specific program funds
and reimbursement of patient services such as Medicare, Medicaid and other third-party payers.

1980s -Emergence of Informatics Field

The field of Informatics emerged in the healthcare industry and nursing. NI became an accepted specialty and many
nursing experts entered the field. Technology challenged creative professionals and the use of computers in nursing
became revolutionary. The need for nursing software evolved and nursing education identified the need to update
practice standards, determine data standards, vocabularies and classification schemes that could be coded for Computer-
based Patient Record Systems (CPRSs).

Many mainframe HISs emerged with nursing subsystems that documented several aspects of the patient record including
Kardex, results reporting, vital signs and other system that documented narrative nursing notes via word-processing
packages. Discharge planning systems were also developed and used as referrals to community healthcare facilities in the
continuum of care.
The microcomputer, widely known as the personal computer (PCs) emerged that made computers more accessible,
affordable and usable by nurses. It served not only terminals linked to mainframe PCs but also as stand-alone systems or
workstations.

1990s -Affirmation of Nursing Informatics as Specialty Field

Computer technology became an integral part of healthcare settings, nursing practice and nursing profession. Professional
organizations identified initiatives that addressed IT and informatics. Policies and legislation were adopted promoting
computer technology in healthcare including nursing.

The nursing profession became actively involved in promoting NI. NI was approved by American Nurses Association
(ANA) as a new nursing specialty.

The need for computer-based nursing practice standards, data standards, nursing minimum data sets and national
databases emerged concurrent with the need for a unified nursing language including nomenclatures, vocabularies,
taxonomies and classification schemes. Nurse administrators demanded that HISs should include nursing protocols and
nurse educators continued to require use of innovative technologies for all levels and types of nursing and patient
education. Nurse researchers required knowledge presentation, decision support, and expert systems based on
aggregated data.

The 1990s bring about development of smaller and faster computers –laptops and notebooks, workstations, Local Area
Network (LANs) and Wide Area Networks (WANs). The internet made it possible for the information and knowledge
databases to be integrated into bedside systems.

The internet brought new cyberspace tools. By 1995, the internet introduces electronic mail (e-mail), file transfer protocol
(FTP), Gopher, Telnet and WWW protocols. The Web became the means for communicating online services and
resources.

Post 2000-Rapid Growth and Development in NI

Healthcare and nursing undergone developments such as wireless point of care, open source solutions, regional database
projects and increased IT solutions on healthcare environment. Clinical information systems became individualized in the
Electronic Patient Record (EPR) and patient specific systems considered for the lifelong longitudinal record or the
Electronic Health Record (EHR). Mobile computing devices were also introduced such as Personal Digital Assistants
(PDAs), Tablet computers and smart phones. The Voice over Internet Protocol (VoIP) promises to provide cheap voice
communication for healthcare organizations. The prediction of smart cards was realized in Europe (Germany).

The internet has provided a means for development of clinical applications. Critical care units are monitored remotely by
health providers. Telenursing, a recognized specialty since the late 1990s, is increasing in popularity and providing patient
care in an efficient and expeditious fashion.

The Health Insurance Portability and Accountability Act of 1996(HIPAA) was enacted post year 2000 to
streamline health care transactions and reduce cost. Standardized transaction and code sets were implemented in early
2004 to protect security and ensure privacy and confidentiality of healthcare data. The legislation recommended
healthcare providers to use Provider Identification Number (PIN).

Four Major Nursing Areas

The historical perspectives on nursing that shaped the need for computers, information technologies and informatics can
be describe through focusing on major areas in nursing

Nursing Practice

Nursing practice has evolved and changed radically. It has become an integral part of the EHR. Computer systems with
nursing, and patient care data, nursing care plans are no longer separate subsystems of the computerized HISs, but
rather integrated into one interdisciplinary patient health record in the EHR. The need for an interdisciplinary EHR resulted
because of the many initiatives proposed and promoted by the nursing profession as well as by the other health care
providers. They all require patient care data to track the care process. Further nursing practice data emerged with the
introduction of several nursing terminologies that were recognized by the ANA as coded terminologies usable for the EHR.
They are used to assess problems, document care, and track the care process, and measure outcomes. Thus, the
electronic version of nursing practice –the computer –has revolutionized and transformed nursing practice.

Nursing Administration

Nursing administration in hospitals has also changed with the introduction of the computer that links nursing departments
together. Most hospital policies and procedure manuals are accessed and retrieved by computers. Furthermore, work load
measures, acuity systems and other nursing department systems are online and integrated with the hospital or patient’s
EHR system or in separate nursing department systems. The internet is being used by nurses to access digital libraries,
online resources, and research protocols at the bedside.

Nursing Education

The computer has radically changed nursing education. Most universities and schools of nursing offer computer-enhanced
courses, online courses (open university), and/or distance education. Campus wide computer systems are available for
students to communicate via e-mail, transfer data files, access digital libraries, and retrieve online resources of millions of
Internet sites. An email accounts is considered a gateway to these possibilities.

New educational strategies require different methods of teaching. The advent of computers in educational technology has
greatly revolutionized teaching methodologies and strategies. Today, most faculty members use the Internet to teach
courses via the Web and communicate with other students via email. The students on the other hand have to be more
active and assume more responsibility for their education that can be enhanced through the use of the Web. The WWW
facilitates student-centered instructional settings creating a motivating and active learning environment. Finally, time,
distance and cost are no longer barriers to educational programs.

Nursing Research

Nursing research provides the impetus to use the computer for analyzing computer data. Software programs are available
for processing both quantitative and qualitative research data. With the advancement of computer technology databases
supporting nursing research emerged, principally for online searching and retrieving information from the electronic
bibliographic information systems or other databases that contain relevant healthcare content, such as drug data. The
internet also provides online access to millions of Web resources around the world which have increased the capabilities
and expanded the field of nursing research

Standard Initiatives

The third significant historical perspective concerns standard initiatives focusing on nursing practice standards, nursing
data standards and healthcare data standards as well as federal legislation that impact on the use of the computer into
nursing:

Nursing Practice Standards

There are two professional organizations that pioneered the setting of standards in the nursing practice:

 American Nurses Association (ANA)-is considered as the official nursing organization that contributes in the
development and recommendation of standards of nursing practice worldwide. In 1998, the ANA published the
Standards of Clinical Nursing Practice which focused not only on the organizing principles of clinical nursing
practice but also the standards of professional performance. They also recommend that the nursing process serve
as the conceptual framework for the documentation of nursing practice.
 Joint Commission on Accreditation of Hospital Organizations (JCAHO)-focuses on the need for adequate records
on patients in hospitals and practice of standards for the documentation of care by nurses. They also
 recommended acuity systems to determine resource use as well as required care plans for documenting nursing
care. JCAHO described the required contents of an EHR (example: collection and organization of electronic data)
though the publication of their recent manual.

In the Philippines, standardization of the nursing profession was instigated by the Philippine Nurses Association (PNA),as
a member of the International Council of Nurses, founded way back September 2, 1922 and the Board of Nursing which
was empowered by the Republic Act 9173.

Nursing Data Standards

Nursing data standards has emerged as a new requirement for the EHR. There are 13 nursing terminologies that have
been recognized by ANA such as the Critical Care Classification (CCC), Nursing Outcomes Classification (NOC) and Nursing
Information Classification (NIC).

The ANA is the worldwide organization responsible for the recognition of the terminologies in nursing education. Other
organizations that contribute to the standardization of nursing data are as follows:

 American Society for Testing and Materials (ASTM)–The ASTM facilitates student-centered instructional settings
creating a motivating and active learning environment
 High Level Seven (HL7)–Health Level Seven is one of several American National Standards Institute (ANSI)
-accredited Standards Developing Organizations (SDOs) operating in the healthcare arena. Most SDOs produce
standards (sometimes called specifications or protocols) for a particular healthcare domain such as pharmacy,
medical devices, imaging or insurance (claims processing) transactions.
 International Health Terminology Standards Development Organization (IHTSDO)–is a not-for-profit association
that develops and promotes use of SNOMED CT to support safe and effective health information exchange.
SNOMED CT is a clinical terminology and is considered to be the most comprehensive, multilingual healthcare
terminology in the world.
 National Committee on Vital and Health Statistics (NCVHS)–a statutory public advisory body to the Secretary of
Health and Human Services (HHS) that has a 57 year history of advising HHS in the areas of health data, health
statistics, privacy and national health information policy. The members are leaders and experts in their fields, and
the NCVHS has a reputation for open, collaborative processes and ability to deliver timely, thoughtful, and
practical recommendations.

TERMINOLOGIES

 Computer –it is a general term referring to Information Technology (IT) and computer systems. In nursing, it is
synonymous to Nursing Information Systems (NIS), nursing computer applications and Nursing Informatics (NI).
Computers are used to manage information in patient care, monitor quality of nursing care and evaluate care
outcomes. Computers with networks are now used in communicating data via the internet, accessing resources
and interacting with patients on the World Wide Web (WWW).
 Nursing Informatics–it refers to the integration, of nursing, its information and information management with
information processing and information technology to support the health of the people worldwide (International
Medical Informatics Association, 1998). It is a specialty that integrates nursing, computer and information science
to manage and communicate data, information and knowledge in nursing practice. It facilitates the integration of
data, information and knowledge to support patients, nurses and other providers in their decision-making in all
roles and settings. This support is accomplished through the use of information structures, processes and
information technology (American Nurses Association, 2006).
 Clinical Information Systems–this can be used interchangeably with Electronic Health Information Systems
(EHR-S), computerized patient record and electronic medical record. It refers to a set of components that form
the mechanism by which patient records are created, used, stored and retrieved and usually located within a
healthcare provider setting. It includes people, data, rules and procedures, processing and storage devices,
communication and support facilities (Institute of Medicine, 1991).
Significant Landmark Events

Shown in the following table are the highlights in the history of nursing informatics: