Keywords

Technological advances in society and in the delivery of health care, governmental policy implementation and funding, private investment/funding, and subsequent accreditation requirements in practice and education settings set the stage for many of the documented advances in nursing informatics. Other drivers of nursing informatics include changing health needs of populations such as an increasing elderly population with more chronic diseases; renewed emphasis on the individual’s responsibility for health maintenance and self care; the need for improved efficiency, patient safety and evidence-based care; and requirements for economic data related to nurses, still the largest health profession impacting health, wellness and wellbeing.

This chapter highlights these drivers and the expanding roles for nurses as administrators, educators, scientists, and leaders in industry and government. In these roles and in all their varied roles in practice settings, including those of advanced practice nurses and nurse researchers, they represent the voice of their profession – in hospital-based acute care, ambulatory care, home health, schools, the workplace, community centers, home health, public health, and nursing homes. Finally this chapter explores the emerging and future impact of new technologies on patients and families, such as provider-driven dashboards populated with data from electronic health records, personal health records, and mobile health devices. Their impact, combined with society’s changing health and medical care needs, gives rise to changing requirements and roles for nurses in relation to nursing informatics.

Despite the fact that nurses in different roles have been involved in modern informatics for over 25 years with some of the first contributions recorded in the 1970s, the term “nursing informatics” was not seen in the literature until 1984 [34]. A major reason was that nursing informatics was included in the broader, overarching term “medical informatics,” a term used since the mid-1970s, referring to information technologies that concern patient care and medical decision making [84]. According to Saba and McCormick [66], nursing, medical, dental informatics overlap in several important areas including, but not limited to, information retrieval, patient care, decision support, human-to-computer interactions, information systems, computer security, and computerized patient records. Recently, the term “health care informatics” emerged to describe the “integration of health sciences, computer science, information and cognitive science to assist in the management of health care information” [66].

1 Nursing Informatics: A Historical Overview

In any historical discussion of informatics, it must also be acknowledged that major elements of nursing informatics are a significant part of nursing’s roots going back to Florence Nightingale, the first nursing informatician [34]. Considered the founding mother of modern nursing and a very early patient safety advocate, Nightingale pushed for hospital reform with statistical analysis by collecting, tabulating, interpreting and graphically displaying data to improve patient care during the Crimean War [55]. According to Ozbolt and Saba [57], 137 years before the Institute of Medicine reported that medical errors were killing up to 98,000 in American hospitals, “Nightingale called for standardized clinical records that could be analyzed to assess and improve care processes and patient outcomes.” Foster and Conrick [28] agree that “Florence Nightingale began gathering the first minimum health data over a century ago.” Yet over 100 years would pass before Harriet Werley became the first designated nurse researcher at Walter Reed Army Research Institute. In the late 1950s, she was one of a few people who consulted with IBM regarding possible uses of computers in health care; these experiences led her to recognize the need for what would be known as the minimum set of standardized nursing data to be collected on every patient [82]. This resulted in a committee being appointed by the American Nurses Association (ANA) focused on nurses’ use of information for communication and decision making [1]. Going forward, modern nursing informatics continued to build on this seminal work. The advances recorded in the 1970s in subsequent decades expanded the influence and contributions to health care, patient safety, and care across the continuum to persons, families, and communities [37].

1.1 The 1960s

Computer terminal s located at the nursing stations were critical to the nurses’ acceptance of a hospital information system (HIS). In the early 1960s, Spencer and Vallbona [73] at the Texas Institute for Rehabilitation and Research (TIRR) used specially designed source documents for recording at the patient’s bedside the nursing notes and the patient’s vital signs. The data were then keypunched and read into the computer, following which progress notes were printed, and vital signs were plotted for filing in the patient’s paper-based chart [68]. At the University of Missouri-Columbia Hospital, IBM 1092 terminals with multiple function buttons and plastic overlay mats to define different data sets were placed at nursing stations [44]. At the Children’s Hospital in Akron, Ohio, DeMarco [19] reported the installation of an IBM 1710 system with data entry terminals with keyboards consisting of rows of push buttons that served as code keys for order entry, admissions, dietary services, and census reports. This system completely replaced the Kardex file system in which orders had been manually written. To enter an order for penicillin, for example, the nurse started at the left side of the keyboard, entered the type of order (its function code) in the first two rows, the patient’s code number in the next three columns, the order number (of the medication and its strength) in the next four columns, how frequently the order should be carried out in the next two rows, and the type of order (modifier) in the last row on the right. Instantly, the order was decoded and printed back on the output printer. However, push-button, key-coded type terminals were soon found to be too slow and inflexible.

The United States Congress amended the Social Security Act to include Medicare and Medicaid in 1965. This federal law now required nurses to document care and be provided to Health and Human Services in order for the hospital to qualify for reimbursement. Addressing this requirement in 1965, nurses at San Jose Hospital recorded their observations on a checklist form that could be read by a mark-sense reader that produced punched cards. The cards were then processed through an IBM 1441 computer, which created the records necessary to print out the nurses’ notes. Forms were developed for medical, surgical, pediatric, and maternity nursing units [56]. In 1966 the Institute of Living in Hartford, Connecticut, reported that its nurses checked off statements on a machine-readable form that described their patient’s status. The completed forms were picked up daily and read into a computer. The computer, in turn, printed out a checklist that incorporated the additional written observations, and thus created a narrative statement [63]. The precoded cards and forms were too inflexible, however, and were replaced by interactive terminals in the 1970s when nursing information systems began to include visual display terminals at the nursing stations. These interactive terminals permitted the selection of data from menu listings. Some terminals had light-pen or touch-sensitive data selectors; all had keyboards for entry of other non-displayed, pre-formatted data [8]. It was the hope that one of the main benefits of interactive display terminals would be that it would encourage physicians to enter their orders directly, without any nurse or clerk intermediaries, to eliminate transcription errors and to provide online clinical decision support to physicians. However, nurses accepted these display terminals more than did physicians.

Stimulated by the advances in technology, the need for data/information input and the growing need to utilize the data for research and decision-making, a national working conference was held in 1969 to “develop a ‘minimum basic set’ of data elements to be collected from all hospital records at the point of patient discharge from hospitals” [35]. At the same time, advances in computer design made it feasible to manage data using computers. Thus the problem was the need to identify available and reliable data elements that would be consistent across multiple users and settings.

1.2 The 1970s

In 1974, a Uniform Hospital Discharge Data Set (UHDDS) was adopted by Health and Human Services; however, the items focused on medical diagnosis and treatments. Nurses provided much of the clinical care 24-7, yet there was no nursing clinical data in the dataset. In 1977, this prompted nurses to build on Werley’s earlier work (REF) and to move forward with the development of the Nursing Minimum Data Set (NDMS). This work was not completed until the mid-late 1980s.

During this important decade, according to Ozbolt and Saba [57], the “first reports of computer applications in nursing began to appear in the scholarly literature.” Zielstorff was hired into the Laboratory of Computer Science at Massachusetts General Hospital (MGH), where she contributed a nursing perspective to funded grants. In 1971 Massachusetts General initiated a nurse-practitioner project designed to allow nurses access to computer-stored medical records. Using a video terminal with a light-pen data selector, after entering the patient’s identification number, a nurse could retrieve and review current medication orders, recent progress notes and laboratory test results. Nursing progress notes were entered by selecting appropriate data items from a series of displayed frames. A teletype printer could print out a data flow sheet for that office visit. The project was based on Barnett’s pioneering work in his laboratory at MGH [29]. Later in the 1970s, Zielstorff edited the first monthly column on computer applications in nursing in the Journal of Nursing Administration and subsequently complied/edited one of the first textbooks, Computers in Nursing [85].

Ball [5] also wrote that some vendors of hospital information systems (HIS) planned their basic philosophy in HIS design on the concept that activity at the nursing station is the activity most directed to patient care and therefore the most important. Ball and associates [6] further wrote that nurses constituted the largest group of health care professionals in any hospital and accessed the HIS more often than any other category of health care professional. Nursing functions were always central to the care of hospital patients, and nurses’ services to patients directly complemented those of physicians. Two early developments reflected this reality. At the El Camino Hospital in Mountain View, California, nurses assisted in the development of an integrated system for nursing care planning, documentation, and feedback working with Technicon Medical Information Systems [17]. At the Clinical Center of the National Institutes of Health, McCormick and Romano were among nurses focused on interdisciplinary efforts to include documentation of nursing data when implementing Technicon there [57].

Federal funding from a predecessor of the Agency for Research and Quality, the National Center for Health Services Research (NCHSR) helped support the development of HIS that included nursing care planning. In addition, computer vendors contributed substantially to the development of information systems (NISs). Saba and McCormick [66] defined NISs as computer systems to collect, store, retrieve, display, and communicate timely information needed to administer nursing services and resources; to manage patient information for the delivery of nursing care; and to link nursing practice, research, and education.

The technical design of a NIS was generally similar to that for any clinical department. The NIS had to be able to support all nursing functions, to have computer terminals acceptable to nurses, to be integrated into the overall HIS, and to provide data security and integrity [87]. However, the detailed functional requirements of a NIS were sufficiently different that nurses had to actively participate in determining the NIS requirements [22].

Special considerations were needed for database and knowledge-based requirements to satisfy nursing diagnoses, interventions, and evaluations [58]. Furthermore, specifying the information system requirements for the nursing services was critical for the overall HIS. Ball [4] advised that a nursing information expert, a crucial role in nursing, must take a leading role on the selection team in search of an effective computer-based HIS. As the importance of nursing services to direct patient care became increasingly recognized, larger HISs worked closely with nurses to design and develop specialized NISs. Saba [68] wrote that the functions of a hospital NIS were to classify patients for nurse staffing, to schedule nurses, manage nursing personnel, and administer quality assurance programs. Ball [3] and Hannah wrote that the broad goal of a NIS was to free nurses to assume the responsibility for systematic planning of nursing care for patients and their families, for continual review and examination of nursing practice for quality assurance, for applying basic research to innovative solutions to patient care problems, and for devising creative new models for the delivery of nursing care.

Beyond the focus on NISs for hospitalized patients, in the 1970s another source of federal support was the Division of Nursing within Health and Human Services which funded nursing research as well as education. Beginning in 1975, a series of grants to the Visiting Nurse Association of Omaha, Nebraska resulted in the development of the Omaha system by Simmons, Martin and colleagues (Martin and Simmons). Consistent with the need for federal reporting related to Medicare and Medicaid, the initial purpose of this system was to use computer-based data in record systems to meet reporting requirements and to improve the quality of care.

In 1973, Gebbie and Lavin organized the first conference focused on standardizing nursing diagnosis. Subsequently, a professional association was developed, known as the North American Nursing Diagnosis Association. Chaired by Gordon, this group developed standardized nursing terminology and further refined the criteria and taxonomy that were presented as an organizing framework for nursing diagnoses in 1982 [54].

1.3 The 1980s

In the 1980s, significant progress was made in nursing informatics not only in technology that directly impacted practice, in education, research and advances in nursing professions and interdisciplinary associations, in education and research. During this important decade, significant attempts continued to be advanced to capture nursing’s unique contributions to patient care and ability to track those contributions to outcomes. Also, continued significant attempts to standardize nursing language and data elements and legitimate nursing informatics as a specialty in the profession of nursing.

With the advent of the personal computer in 1980, vendors also began to develop specialized, microcomputer-based video display terminals with simplified keyboards custom-tailored for nursing functions to be used at the patient’s bedside. These bedside terminals were connected to nursing-station units that were linked by LANs into the HIS [61]. This allowed nurses to record directly into the computer, at the time of caring for the patient, the patient’s vital signs, the nursing observations, and the medications given. Printouts from the terminal located at the bedside included graphs of the vital signs and a variety of useful reports.

The 1981 Fifth Annual Symposium on Computer Applications in Medical Care (SCAMC) held what was its first full session on nursing applications of computers, organized by Virginia Saba [70]. McNeely [50] emphasized the importance of nurse participation in the planning of the NIS for the Clinical Center of the National Institutes of Health (NIH). Zielstorff [86] reviewed the status of Nursing Information Systems (NIS) administrative applications in hospitals. Charters described the use of microcomputers to automate 80 % of nursing service paperwork [15].

At a conference held in 1981 at the Clinical Center of the National Institutes of Health and attended by more than 700 nurses, it was agreed that nurse administrators needed to have a voice in purchasing and implementing decisions, authority for controlling nursing database development, a stake in the development of content and standards of nursing documentation, and an agreed-upon taxonomy for the nursing process, including nursing diagnoses [83].

In 1984 a distributed system of microcomputers was installed at the LDS Hospital in Salt Lake City, with four display terminals and one printer at each 48-bed nursing division; and a group of 30 display terminals were connected to each microcomputer. Patient data were entered and reviewed at each local terminal, and eventually were transferred from the microcomputer into the central Tandem computer. Through menu selection from the displays, nurses had access to order-entry and review, results review, and discharge and transfer functions. The system generated nursing care plans and performed some charting functions [41]. The system automatically measured patient acuity or degree of dependency based on nursing time spent with each patient, in accordance with preassigned time factors as the nurse entered aspects of patient care during a work shift [42]. Nurses wanted to capture source data as close to the patient’s bedside as feasible; so with the advent of lower-cost minicomputers connected to smart terminals, these terminals were placed at the patient’s bedside. In 1984 LDS Hospital placed such terminals at the bedsides in their ICU [14]; by 1987 the hospital had 400 such terminals in their general nursing divisions. They performed a study that compared on-line nurse charting on one nursing unit where nurses used terminals located at the bedside with charting by nurses using similar terminals located at the nursing station. The researchers evaluated nurses’ satisfaction, amount of use of each terminal, and the number of items being double charted (written down and then entered later). The results were so favorable that by the end of the 1980s the LDS hospital was installing bedside terminals throughout all nursing units [40].

By the mid-1980s portable handheld terminals appeared that permitted the nurse to enter patient data at the point of care. The ability of nurses to access the patient’s computer-based record directly at the point of care was expected to improve the quality and documentation of nurses’ bedside care and to save nursing time [75]. The patient’s vital signs and the medications given were entered directly into the patient’s computer-based record, eliminating the paper charting process and allowing nurses more time for other nursing functions. At the end of the 1980s a medical information bus was developed, that was a standardized connection, so any vendor’s bedside technology could take data from the bedside terminals and integrate the data into the HIS database. This bus was a standardized connection, so any vendor’s bedside technology could communicate with the HIS database [21].

Hospitals began to use bar codes to identify patients, using bar-coded wristbands, bar-coded medical records, blood-bank samples, laboratory samples, and x-ray folders. For clinical applications that allowed the use of bar-code labels, using a wand bar-code reader connected to, or communicating by radio to, a computer was a much faster method for nurses than was typing to enter the data contained on the label, and it was more accurate [30]. In 1986 M. Monahan and associates at the University of Hospitals of Cleveland, Ohio, reported the use of handheld terminals that, after manual entry of the patient’s identification, used barcode readers to scan and enter automatically nurse identification and relevant patient conditions from a listing of 61 possible nursing diagnoses. After all patient and nursing data were entered into the terminal for the day, the data were transmitted to the hospital computer via any telephone, since a modem was located in the back of the terminal. Advantages of the technology included its affordability and a data entry procedure that was reported to be easily learned by 1100 nurses on 33 inpatient units for its rapid data entry [52]. However, because there was not a two-way link to the hospital computer, patient identification numbers could not be verified to determine whether they were correct. This deficiency was corrected when the vendors (1) provided portable handheld terminals with barcode readers that communicated with a base unit via radio frequency and (2) set up communications between the base units and nursing-station terminals linked to the HIS over existing telephone lines [36]. In 1988 Childs [16] described how a nurse, with a handheld terminal containing a barcode reader, read the patient’s identification number from the code stripes on the patient’s wristband before giving a medication to verify that the patient was due at that time for that specific medication. When the computer identified matching bar codes, it authorized giving the medication and recorded the date and time. By the end of the 1980s, bedside systems were available from a variety of vendors, so a hospital could select a system with bedside terminals connected to the main HIS, bedside terminals connected to the nursing station in the HIS, or portable point-of-care terminals interfaced by radio frequency to the nursing system of the HIS.

Nursing services have their own administrative and managerial responsibilities, in addition to direct patient care functions [69]. Nursing management functions include: staffing and scheduling the nursing staff, maintaining personnel records, administering quality-assurance programs, managing resources used, and preparing nursing-service budgets. Traditionally, nurse staffing had been based primarily on the ratio of hospital patients to nursing personnel. A group at Johns Hopkins Hospital reported studies that indicated that functional activity planning and budgeting for nursing services improved these activities [72]. In the 1980s NISs began to provide nurse staffing recommendations based on some classification system of patients’ status. Nurses assessed their patient’s acuity level and entered the appropriate data by selecting descriptors from a displayed list (or menu); patients were then categorized as to the probable hours of nursing care they would require, and then staffing requirements for the nursing shift were recommended [66, 68]. Also in the 1980s reports appeared that described automated nurse-scheduling and nurse-staffing systems using personal computers. At the Milwaukee County Medical Complex, Flanders [27] reported that an IBM personal computer (PC) had been operational for 20 months preparing schedules for 1500 nurses, generating 4–6-week schedules for several classifications of nursing staff. The developmental and operational costs of the system were favorable due to the system being microcomputer-based and totally under the nursing department’s control. Kogut [45] at the Montefiore Medical Center in the Bronx, New York, reported the installation in 1983 of a patient acuity and nurse-staffing system for 28 nursing units using a personal computer with a series of displayed menus for item selection.

Saba [71] reported that, as a result of the Joint Commission on Accreditation on Hospitals (JCAH) recommendation that nurse staffing should be based on patient cuity/classification systems instead of the traditional nurse-to-patient ratios, such systems became the major method to administrate nursing services in hospitals in the 1980s. Saba [68] described four patient classification systems then being used for nurse staffing:

  • The San Joaquin System, which used nine indicators of patient care requirements

  • The Medicus Patient Classification Module of Nursing Productivity and Quality of Patient Care System (NPAQ), which used 36 indicators of patient care

  • The Grace Reynolds Applications and Study of PETO (GRASP), which used time requirements for 60 nursing activities

  • The Halloran and Kiley Nurse Management System based on nursing diagnoses.

Nursing Information Systems (NISs) also had a role in bed assignment and control. Nurses regularly confirmed bed census with the admitting service; assigned beds on request of the admitting service; notified housekeeping when a bed needed to be prepared; notified dietary service on bed changes and dietary requirements; and notified the business office when a patient was discharged, so that a bill could be prepared. NISs were also used to administer the quality assurance programs of nursing services on patient care, and to monitor adherence to predefined quality assurance standards [68].

According to Saba [68], the steps of the nursing process in direct patient care could be classified as collecting data, diagnosing, setting objectives (with priorities and target dates for achievement), choosing and implementing interventions, and evaluating the effectiveness of care. The patient care nursing functions that required the entry, retrieval, and communication of data in the nursing system of a HIS included: physicians’ orders, patient status reports, medication administration, nursing diagnoses, and patient care plans [77]. The Nursing Information System (NIS) database containing the data documenting what nurses did in their practice, included patient interventions in response to medical orders; and relatively independent nursing interventions based on nursing diagnoses relating to patient needs, which encompassed air, circulation, food and fluid, elimination, sleep and rest, comfort and pain, hygiene and skin, and others [62].

As had users of other NIS systems, nurses recognized the importance of developing their own standard sets of data for nursing practice. By the mid-1980s, Gordon [31], at the Boston College of Nursing in Chestnut Hill, Massachusetts, had proposed a standard nursing data set that included 17 data items. Werley [81], Lang, and associates at the University of Wisconsin-Milwaukee School of Nursing tested a standard nursing minimum data set of 16 data items. These data sets included: items representing patient demographic variables (age, gender, ethnicity, marital status, next of kin, and residence); provider variables (facility providing care, primary nurse identification, admission and discharge dates, disposition, anticipated source of payment); and care provision variables (functional health status, nursing diagnoses, projected and actual outcomes, nursing treatment orders, medical diagnoses, medical treatment orders, diagnostic and surgical procedures). This data set was to be applied to nursing practice in at least five settings including hospitals, ambulatory care, home care, community, and long-term care. Assisted by funding from the Hospital Corporation of America (arranged by Simpson) and sponsored by IBM (contacted by Werley based on early consulting relationships) and the University of Wisconsin – Milwaukee School of Nursing, the Nursing Minimum Data Set became a reality in 1985–1986.

Ball and Hannah [6] described two general approaches to the automated recording of nurses’ notes on their observations of patients. The first method employed the development of a group of frequently used descriptive terms, and the earliest nursing systems used machine-readable forms from which the nurse selected the appropriate statements that applied best to the patient. The marked forms were batch processed, and the data were read into the computer. Later, display terminals connected to the computer permitted online processing of nurses’ notes with a computer-based library of frequently used phrases arranged in subject categories. For example, if the nurse chose the phrase, patient’s sleeping habits, a displayed menu of standard descriptions appeared, additional comments were allowed; and when completed the nursing station printer immediately printed a complete narrative that could then be attached to the patient’s paper chart.

The second method used a branching questionnaire for data entry. The computer terminal displaced an initial list of subjects from which the nurse would select the one most appropriate for the patient. For example, if describing skin conditions, the nurse then would be led through a series of questions, such as skin intact, yes, no? If answered yes, then other questions followed until completion of the desired observation. The computer then processed the information and provided a narrative printout for the patient’s chart.

Nurses needed to enter data describing the patient’s status as to mental acuity, physical abilities, vital signs, fluid balance, and other data. They also entered terms representing nursing diagnoses, which classified the patients’ problems that nurses were licensed to treat. Like medical diagnoses, nursing diagnoses were based on patients’ signs and symptoms. The North American Nursing Diagnosis Association (NANDA) [54] developed a classification for nursing diagnoses using a four-character code modeled after the International Classification of Diseases (ICD); examples at that date were: Y.20.3 for diarrhea, Y.25.1 for hyperthermia, and Y.50.4 for impaired physical mobility [26]. Following the establishment of their patients’ diagnoses, nurses prepared nursing care plans for each patient; then carried out these plans, and documented all results as a part of the traditional nurses charting activities. Computer-based patient care management plans were built into some of the earliest HISs, such as those used at TIRR. In the late 1960s, the TIRR information system prepared treatment plans and generated department lists of tasks to be carried out by the nursing units [76].

Saba [68, 71] described two types of nursing care planning systems that were available in the second half of the 1980s:

  • Traditional systems focused on medical diagnoses or diseases; these consisted of elements that addressed signs and symptoms, and contained protocols that reflected the medical orders for nursing care for each diagnosis.

  • New nursing care planning systems that focused on nursing diagnoses; these set forth the nursing process that consisted of assessing and diagnosing the nursing problems for care of the patient and then planning, intervening, and evaluating the outcome of care.

Although Ozbolt and Saba [57] found agreement on how to operationalize nursing data elements consistently across systems, other systems were developed in addition to NANDA. One of these was the Omaha System, which provided a practical approach to recording nursing diagnosis, interventions and outcomes. Another was the Home Health Care Classification System developed by Saba and research colleagues at Georgetown University in the late 1980s, which classified home health Medicare patients as a method to predict resource requirements and measure outcomes [67]. Later known as the Clinical Care Classification (CCC), Saba’s system was expanded from home health and ambulatory care settings into other settings and was accepted by the Department of Health and Human Services as the first national nursing terminology that allowed nurses, allied health professionals, and researchers to determine care needs (resources), workload (productivity), and outcomes (quality).

Crosley [18], at Long Island Jewish-Hillside Medical Center in New Jersey, and Light [47], at Crouse-Irving Memorial Hospital associated with Syracuse University, reported on the use of IBM’s computer-based nursing care plan developed as a separate application module in its HIS, developed earlier at Duke University and announced at IBM in early 1978. This nursing system displayed a set of screens labeled as nursing diagnostic category, signs and symptoms, related factors, patient outcomes, nursing orders, and evaluation. Selections were made from items listed in the series of displays by use of a light pen selector, supplemented by keyboard data entry when needed. The computer printed out a copy of the aggregated data that had been entered, and this printout constituted the patient’s care plan and was placed in the patient’s paper chart [18]. Jenkins [38], at the University of Tennessee in Knoxville, described the McDonnell Douglas Patient Care System, which permitted nurses to develop care plans with four elements: the problem description; the etiologies; the goals of treatment; and the interventions. If the system did not include desired information, nurses could modify the plan using a free-form comment function. Saba [68] reported that HISs in which the nursing subsystem was primarily used for nursing care planning included Shared Medical Systems, Ulticare, the LDS Hospital’s HELP System, and the NIH’s Technicon System.

After physicians began to develop expert systems to aid them in their clinical decisions for patients’ medical problems, some nurses began to develop nursing expert systems to provide decision support in care plans for patients’ nursing problems. Such nursing expert systems usually required using a computer terminal that permitted the user to ask the system specific questions about the patient’s problems, and to receive relevant information. As in any expert system, such responses required a knowledge base of information obtained from the literature or from experts in the field and a mechanism for applying the expert knowledge to the specific questions asked about the patient’s problem. A common technique was for the computer to ask the nurse a series of questions about the patient. With the information thus obtained about the patient and using the knowledge base, the program suggested diagnoses and alternative managements [46].

By the early 1980s, some NISs were available that provided a baseline assessment guide using information that included the patient’s perceptions of: chief complaint, health history, medications, neurological status, mobility, activities of daily living, sleep/rest, comfort/pain, nutrition, psycho-social status, respiratory, circulatory, elimination-bowel and urinary, reproductive, and integumentary items [2]. After guiding the nurse through the collection of these data, the system suggested diagnoses to consider. Once a diagnosis was established, the nurse developed a care plan selected from a list of suggested alternative actions. Lombard [49] at Crouse-Irving Hospital in Syracuse, New York, described their nursing system, which had patient care plans developed by a consensus of nursing experts for such common diagnoses as anxiety, pain, decreased mobility, dependency, disorientation, impaired self concept, impaired skin integrity, impaired transport, respiratory impairment, and others.

The Creighton Online Multiple Modular Expert System (COMMES) was developed by Evans [23] at Creighton University as an educational tool for different health professionals; but the system found its best application as a consultant clinical nursing expert system. Using Creighton’s time-sharing computer, a nurse could request a protocol for the care of a specific condition (such as emphysema) and then use the protocol consultant of COMMES to tailor a set of recommendations into an actual care plan for the specific patient. By guiding the nurse through the patient’s signs and symptoms, the system’s nursing diagnosis consultant would aid in arriving at a diagnosis and possible etiologies [24]. In addition, the system could provide a general nursing plan by medical diagnosis or by a diagnosis related group (DRG). Ryan [64, 65] described COMMES as an expert system that involved the structure of the domain of nursing, with a semantic network based on the conceptual relationships of more than 20,000 terms; having the ability to search heuristically based on if, then rules that explored their relationships. Bloom [10] reported a prototype system for COMMES that used an IBM PC computer. Evans [25] reported that care plans devised by nurses using COMMES were thorough and appropriate. Ozbolt and associates [59] at the University of Michigan also reported developing a prototype expert system for nursing practice. To derive nursing diagnoses from client data, they designed algorithms that consisted of “if, then” decision rules. The decision rules were based upon knowledge derived from the clinical literature, as for example, about normal and abnormal patterns of elimination and self care when applied to bowel elimination problems.

In 1985 a survey of 28 hospital information system vendors found that approximately 86 % of the vendors offered a product to support nursing activities; 88 % of the products supplied featured needs of the nursing manager; 83 % provided a patient classification system; and 25 % provided support for quality assurance activities [60]. A survey conducted in 1988 found 16 vendors who offered a nursing information system (NIS) that supported nurse functions in general medical and surgical units; nurse charting was provided by ten vendors; intake/output calculations and tracking vital signs by nine vendors; results reporting, nurse care planning and graphic charting by seven; interfacing to the HIS and other departmental systems by six; and nurse assessment, medication administration, admission-discharge-transfer, order entry functions, and standard shift reporting by five vendors [20]. Nurses generally accepted HISs better than did physicians. A survey of registered nurses at the 1150-bed Methodist Hospital of Indiana that had used the Technicon MIS for 5 years found that 86 % of the nurses agreed they liked working with the HIS [12]. In the 1980s NISs were probably the most widely used HIS subsystem in the United States.

During the late 1980s, McCloskey, Bulecheck, and colleagues from the University of Iowa began development of what would become known as the NIC, or Nursing Intervention Classification [13]. The first identified comprehensive classification of treatments that both nurses and physicians perform, the NIC was developed with research funding from the National Institute for Nursing Research (NINR) and includes physiological and psychosocial aspects of illness treatment, prevention, and health promotion.

With advances in technology and increased activity in the development of nursing classification systems to standardize nursing data, the American Nurses Association formed a Council in 1984 and adopted a resolution identifying the need for nurses to use information systems for the purposes of collecting and utilizing data in practice, education administration and research, with the specific recommendation that the Nursing Minimum Data Set be tested and implemented [51]. Additionally, the National League for Nursing created a Computers in Nursing forum in 1985 to influence the development of educational materials and advance educational nursing informatics related programming. In 1988, the first graduate education program in nursing was opened at the University of Maryland, led by Gassert and Mills under the leadership of Heller, the school’s dean. Subsequently, nurse leaders introduced informatics courses were introduced elsewhere: Ronald, at the State University of Buffalo; Saba, Georgetown University; and Skiba, at Boston College [57].

During the 1980s, definitions of nursing informatics began to clarify the role of nurses with regard to computer technology. Ball and Hannah [35] modified an early definition of medical informatics to acknowledge that all health care professionals are part of medical informatics. Graves and Corcoran [32] defined nursing informatics as a scientific discipline bringing together nursing science, information science, and computer science. Subsequently, in late 1980s the ANA Council of Computer Applications in Nursing expanded previous definitions by incorporating the role of the informatics nurse specialist into Graves and Corcoran’s definition [32].

1.4 The 1990s

Advances in technology such as the introduction of the internet, the emergence of Web-based applications, and the availability of smaller, lighter computers including personal data assistants (PDAs) shifted the emphasis of nursing informatics beyond hospital walls. According to Staggers and Thompson [74], conceptually-oriented definitions of nursing informatics gained acceptance and began to replace earlier technology-focused definitions. Nurses in informatics roles gained prominence, and in 1994 the ANA published the first versions of the Scope of Nursing Informatics Practice and the Standards of Informatics Practice. By 1995 a certification in nursing informatics as a practice specialty was established by the American Nurses Credentialing Center (ANCC).

During this time, the growing interest in nursing language, data, and standardization led nursing leadership to change the name of the ANA Data-base Steering Committee to the Committee on Nursing Practice Information Infrastructure. Although there was a drive towards a Unified Language System, several nursing languages continued to grow, including Saba’s Clinical Care Classification, the Omaha language which was adopted by some home care and community health nursing agencies across the nation, and Grobe’s Nursing Interventions Lexicon and Taxonomy, published in 1990. During this time, a pilot project in a Rochester Community Nursing Center SBHC (school-based health clinic) where care was provided by Advance Practice Nurses collected data using the Omaha System, ICD-9, and Current Procedural Terminology (CPT codes) “to determine if whether a nursing taxonomy is more sensitive in predicting number, type and costs of health care encounters for population-based care of adolescents in SBHCs” [80]. Additionally, the Nursing Outcomes Classification (NOC) joined the NANDA and NIC classification to complete a varied set of clinical nursing languages [80]. The number of languages, the lack of consensus, combined with varied licensing fees so complicated choices that many health care organizations chose vendor-provided non-standard terms for nursing’s contribution to care, thus hampering the ability to collect data across systems to measure quality or conduct research.

Community Nursing Centers (CNCs), which were an important approach to providing community-based, nurse-managed care in the 1990s, also had informatics challenges specific to nursing documentation without a unified nursing language system. Centers affiliated with the University of Rochester and the University of Wisconsin were challenged by the need to collect, track, and analyze clinical data. In the NLN published book Nursing Centers: the Time Is Now [53], Lundeen and Walker, directors at the two centers, discussed challenges specific to clinical data collection and management for research, health professions education (faculty practice), and health policy purposes. Both leaders identified the need for relational databases for CNC management, staffing, tracking costs and quality of care. Walker and Walker [78] clarified the need for “information engineering” to address six critical success factors for CNCs: “1. Development of diverse revenue streams; 2. Cost control; 3. Providing and documenting quality services (care); 4. Client and faculty practitioner satisfaction; 5. Development of practice-based research; and 6. Integration of the CNC into the educational activities of the School of Nursing.”

In 1990, the American Medical Informatics Association (AMIA) was founded through a merger of three existing informatics associations, one of which was the Symposium on Computer Applications in Medical Care (SCAMC). Since nurses had been involved, a Nursing Informatics Working Group (NI-WG) was formed with Ozbolt as the first chair. Nurses subsequently assumed interdisciplinary leadership roles in AMIA and have continued to current times. The College of American Pathologists worked to integrate nursing concepts into the Systematic Nomenclature of Medicine (SNOMED). Also in 1999, Ozbolt brought together nurse informaticians, experts on terminology, members from the federal government and vendor community, and representatives of professional organizations to attempt to interface languages with semantic interoperability. Although imperfect, the Unified Medical Language System (UMLS) and SNOMED – CT did incorporate nursing concepts. To date, this remains a challenge for progress in nursing informatics.

Nursing informatic s was also gaining acceptance and growing influence with educators and nurse researchers. The University of Utah, University of Colorado, Duke University, and other schools also established graduate programs, and the University of Maryland awarded the first PhD in Nursing Informatics to Staggers. In 1997 at the University of Colorado, Walker, the new dean Walker named Skiba the first Associate Dean for Informatics and Academic Innovations to help develop a new curriculum focused on theory-guided, evidence-based practice with a increased focus on informatics.

Also, with the significant advances in technology identified earlier in the 1990s, Patricia Brennan initiated a new focus on the health benefits that new technologies could provide to consumers and the need for increased computer-based education and support to patients and caregivers in their homes. This emphasis on consumer engagement in care in the turn of the century continues to gain momentum with federal policy initiatives, technological advances, and increasing digital-oriented populations of all ages.

2 The New Millennium: 2000–2014

In 2000, leading developers of nursing terminologies from the U.S., Europe, Latin America, Australia and Asia gathered at a Nursing Terminology Summit conference to try to resolve issues related to nursing terminology with the International Standards Organizations Technical Committee (ISO-TC). Subsequently, the ISO work combined with the work of the Nursing Terminology Summit resulted in integration of nursing concepts and nursing interface terminologies mapped to concepts in SNOMED-CT , ultimately in 2007 becoming SNOMED, an international reference terminology standard.

The need for informatics advancement became an imperative when two reports from the Institute of Medicine related to patient safety were published. To Err is Human (1999) and Crossing the Quality Chasm (2001) created a mandate for improving the quality of care. In 2004, President Bush called for every American to have an electronic health record by 2014 and established the office of the National Coordinator of Health Information Technology. These actions stimulated the need for adopting standards for interoperability of health information transactions across settings. This policy decision resulted in the formation of the Health information Technology Standards Panel (HITSP) in partnership with the American National Standards Institute (ANSI). The other organization created from this federal policy decision was a private, not-for-profit Certification Commission for Healthcare Information Technology (CCHIT) to review and ensure hardware and software products meet adopted standards. The first nursing language adopted was Saba’s Clinical Care Classification System, and nurses have been well-represented on HITSP, CCHIT and involved in other standards setting organizations including SNOMED, Health Level 7 (HL7) and Logical Object Names, Identifiers and Codes (LOINC). After serving in leadership roles in SNOMED and HL7, Warren became the first nurse appointed to the National Committee on Vital and Health Statistics.

Other nurses continue to make contributions related to consumer-driven health care. Continuing her work done in the 1990s on consumer-driven health care, Brennan became the national director of a multi-site research program funded by the Robert Wood Johnson Foundation to develop innovative approaches to personal health records and tools for health management [11]. At the University of Maryland, Nahm and colleagues are conducting research related to the use of personal and family health records to assist family caregivers to manage care of older adults [43].

In 2004, with the leadership of Delaney from AMIA board and Sensmeier at Health Information Management and Systems Society (HIMSS), 18 national and regional nursing informatics groups established the Alliance of Nursing Informatics (ANI), with the AMIA and HIMSS boards of directors agreeing to provide ongoing support, coordination and leadership [33].

In 2004, after President George Bush created the Office of the National Coordinator (ONC), several nurses attending the first HIT summit convened by Brailer, then National Coordinator for Health IT. Since there were no nurses included at the table nor were nurses even mentioned, a group of leaders met and resolved to strengthen the voice of the nursing profession at this important time in history [78]. In 2005, the group held a strategy session to plan for an invitational summit that would bring nurses together from academia, government, and industry in what became the TIGER Initiative, an acronym for Technology Informatics Guiding Education Reform. In 2006, over 100 nurses representing all walks of the profession (not just nursing informatics specialists) met at the Uniformed Services University of the Health Sciences. Together they articulated a vision that would interweave nursing informatics technologies into nursing practice and education. In what they designated as Phase I of TIGER, they identified seven pillars:

  • Management and Leadership

  • Education

  • Communication and Collaboration

  • Informatics Design

  • Information Technology

  • Policy

  • Culture

To gain top level support for nursing informatics, the TIGER leadership scheduled the summit to coincide with the annual fall meeting of the American Association of Colleges of Nursing (AACN) and invited deans from schools of nursing to a reception and “gallery walk” that exhibited a number of emerging technologies.

During Phase II, initiated 6 months after the summit, TIGER reorganized its action plan into nine key areas and formed nine collaboratives. Volunteers in each group reviewed the literature, developed strategies/recommendations for implementation and integration of nursing informatics across all groups within the profession. With grassroots involvement of more than 1500 nurses, the nine collaboratives generated reports in their areas of focus:

  • Standards and Interoperability

  • Health Policy

  • Informatics Competencies

  • Education and Faculty Development

  • Staff Development

  • Leadership Development

  • Usability and Clinical Application Design,

  • Consumer Empowerment and Personal Health Record

  • Virtual Learning Environment.

TIGER Phase III involved dissemination through numerous webinars across professional organizations, universities, clinical settings, and presentations at national and international meetings. Progress made through the TIGER initiative formed the core of the fourth edition of Nursing Informatics: Where Technology and Caring Meet, as reflected in the new subtitle that took the place of Where Caring and Technology Meet used in previous editions [7].

In 2011, TIGER became the TIGER Initiative Foundation connected to the Health Information Management and Systems Society (HIMSS). The TIGER Board of Directors and it director, Schlak, continued to advance competencies through continued dissemination and outreach to nursing specialty and interprofessional groups. The Virtual Learning Environment was launched and a TIGER Newsletter kept nurses active in the initiative informed. In 2014, TIGER became part of the HIMSS organization and continues to offer grass roots nurses and individuals from other disciplines advancement in informatics and opportunities for participation.

During the period of 2005 and 2014, two federal policy initiates have had and will continue to have significant influence on informatics. The American Recovery and Reinvestment Act (ARRA) signed by President Obama in 2009 authorized the Centers for Medicare and Medicaid Services (CMS) to provide incentive payments to eligible professionals and hospitals who adopt, implement, upgrade or demonstrate “meaningful use” of certified electronic health records. ARRA funding continued the race begun by President George Bush for every American to have an electronic health record by 2014 with evolving technologies and interoperability creating both challenges and opportunities for nursing and interprofessional informaticists. The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA), was signed into law by President Barack Obama in 2010 and represents significant change impacting health systems and consumers. This act has increased the focus on reducing hospitalization by improving outcomes of care. Also, with growing knowledge and access to health related information and a shift to emphasis on healthy lifestyles and self management of chronic illnesses/conditions, nursing informatics has the potential to rapidly moving to the forefront in coordination and management of individuals, families and communities through care coordination and coaching using both system and person/family generated data and dashboards [39].

According to Klasnja and Pratt [44], mobile phones are increasingly valuable tools for improving health and managing chronic conditions. With the capability to self monitor healthy behaviors (exercise, food intake) and key measures (glucose, blood pressure), consumers can become actively engaged in improving their own health. Combined with coaching, these mobile platforms combined can help individuals make positive changes in their behaviors [44].

Health coaching enabled by mobile health applications allow coaches to communicate with patients/persons real-time allowing tracking of health and wellness measures such as nutrition, diet, exercise and mood integrated with traditional medical data. Also, mobile health applications enable patients with chronic diseases to focus on more precise, personalized self-management resulting in improved quality of life and fewer hospital visits. Coaching presumes a collaborative paradigm (asking patients what changes they are willing to make) rather than a directive paradigm (telling patients what to do). Nurse informaticists and nurses with an understanding of the use of data and information along with coaching skills can assist persons, caregivers and families in choosing healthy lifestyles, managing chronic conditions and transitioning from health care settings to home with the increased availability and use of personal health records and mobile devices [9].

Future advances in genomics and genetics combined with increasing access by patients/persons and families to the knowledge realtime will increasingly challenge providers and the health care systems and empower patients with just-in-time access to information and decision-support tools for address preferences and personalized care.