Nursing Leadership

Nursing Leadership 22(4) March 2010 : 20-23.doi:10.12927/cjnl.2010.21594
Nursing Informatics

Resolving to Secure a Presence…

Lynn M. Nagle

In the spirit of adopting a meaningful resolution for the new year, turning the page on all disreputable "eHealth" issues in favour of securing a stronger position for nurses in this work seems appropriate. Highly politicized claims of tax dollars wasted, auditor reports, public criticism and a generally increased scepticism of all things "eHealth" have taken their toll on the momentum of the eHealth work effort. But as has been noted by others, there is no better opportunity than a crisis to alter the course of events for the future. As eHealth entities reconstitute and define a "new normal" for the conduct of business, there are likely to be new perspectives and some rethinking of strategy. Hence I proffer that nursing has a prime positioning opportunity within eHealth agendas in the near term.

In the spirit of adopting a meaningful resolution for the new year, turning the page on all disreputable "eHealth" issues in favour of securing a stronger position for nurses in this work seems appropriate. Highly politicized claims of tax dollars wasted, auditor reports, public criticism and a generally increased scepticism of all things "eHealth" have taken their toll on the momentum of the eHealth work effort. But as has been noted by others, there is no better opportunity than a crisis to alter the course of events for the future. As eHealth entities reconstitute and define a "new normal" for the conduct of business, there are likely to be new perspectives and some rethinking of strategy. Hence I proffer that nursing has a prime positioning opportunity within eHealth agendas in the near term.

In past columns I have written about electronic health records (EHRs) and the importance of nursing leadership and nurses' direct participation in the design and delivery of these solutions (Nagle 2008a; Pringle and Nagle 2009). Additionally, I have highlighted (a) the need to identify and develop informatics competencies in practice and education (Nagle 2007a), (b) the merits of standardizing clinical documentation to consistently represent the work of nurses (Nagle 2007b), (c) critical considerations for successful IT adoption, such as human factors and effective integration with clinical work (Nagle 2008b,c) and (d) shifting power differentials with the emergence of personal health records (Nagle 2009). All these elements continue to need leadership and attention from nurses across the country.

Canada Health Infoway continues to work on its agenda to deliver an EHR for 100% of Canadians by 2016 (Canada Health Infoway 2009). To date, cross-country investments in eHealth solutions have exceeded $2 billion, but the work effort and investment needed to complete the job is presumed to be much greater. Nurses across the country have been involved in many of the projects associated with these investments, but to this point, the formulation of a coherent strategy focused on the clinical information requirements and informatics literacy needs of nurses has been lacking. In fact, the Canadian EHR blueprint lacks any explicit reference to the capture of information reflecting the contributions of nurses. This is a prime opportunity to reverse the current invisibility of nursing practice in provincial and national databases.

South of the border, in 2009 President Obama made a significant financial commitment ($19 billion) towards the creation of EHRs for all Americans by 2014. But even before this pledge was made, our American nurse colleagues recognized the need to work together to ensure that nurses would be players and informants in the delivery of solutions. Notwithstanding decades of nurses leading informatics efforts in the USA, they identified the need for a purposeful and action-oriented national strategy to address the needs of nurses in relation to the eHealth agenda. The endeavour began in 2006 with a two-day invitational summit with the intent to delineate a national strategy and work plans to deliver on same. The summit vision was to create a "vision for the future of nursing that bridges the quality chasm with information technology (IT), enabling nurses to use informatics in practice and education to provide safer, high-quality patient care" (TIGER 2009a).

The primary outcome of the summit was the TIGER (Technology Informatics Guiding Educational Reform) initiative, which set forth as its purpose to identify information/knowledge management best practices and effective technology capabilities for nurses (TIGER 2009b). The initiative is underpinned by seven pillars: (1) communication and collaboration, (2) education, (3) cultural transformation, (4) information technology, (5) informatics design, (6) management and leadership and (7) organizational and governmental policy (TIGER 2009c). These themes are, not coincidentally, wholly consistent with those needing attention in Canada. The TIGER participants are "working to catalyze a dynamic, sustainable, and productive relationship" between nursing informatics professional groups and major nursing organizations, including the American Nurses Association, the Association of Nurse Executives and the American Association of Colleges of Nursing and others (TIGER 2009b). With more than 1,500 volunteers, the initiative is "focused on using informatics tools, principles, theories and practices to enable nurses to make healthcare safer, more effective, efficient, patient-centered, timely and equitable." Situated within the initiative are nine working groups that are addressing the following: (1) standards and interoperability, (2) National Health Information Technology agenda, (3) informatics competencies, (4) education and faculty development, (5) staff development, (6) usability and clinical application design, (7) establishment of a virtual demonstration centre, (8) leadership development and (9) consumer empowerment and personal health records (TIGER 2009d). Sound familiar? Reports from the work of almost all these groups are currently available on the TIGER website (http://www.tigersummit.com/9_Collaboratives.html). I encourage you to have a look – the relevance of this work will be patently clear in light of our agenda to deliver an EHR for all Canadians.

To date, investments in nursing and eHealth have been minuscule relative to those being directed towards our physician colleagues. Our work consists of a 24/7 presence in every sector of care; we are more than 300,000 strong, yet our work and contributions to the health of Canadians are not well represented in clinical data sets. Nurses and provider organizations are replicating documentation design work efforts over and over across this country. For all these efforts, the net result is greater variation rather than less, systems that perhaps fail to capture the essence of practice, and no progress towards standardization. Despite some organizations' best efforts to engage nurses and represent nursing in clinical information systems, national and provincial EHR blueprints lack explicit details of nursing assessments, care plans, activities and clinical outcomes. Early evidence from the Health Outcomes for Better Information and Care (HOBIC) initiative in Ontario is pointing the way to some very exciting possibilities for the future (MoHLTC 2009). Access to this small suite of consistently measured and reported assessments has the potential to reveal much about the impact of clinical activities, skill mix and care setting on clinical outcomes. However, in terms of representing nursing in clinical information systems, this is but the tip of the iceberg.

In order to ensure that nurses' contributions to the health of Canadians are captured in national and jurisdictional repositories, the delineation of nursing data standards and associated clinical system requirements remains pivotal. As we remain passive, represented by a mere handful of straining voices rather than a potentially emboldened and booming collective voice, we continue to be relegated to the bottom of the heap. Without assertive action now, the current invisibility of nurses' work in clinical data sets will prevail in the face of electronic health records. We need a Canadian variant of the TIGER initiative now – but in light of recent revelations, we might want to consider a different moniker. I invite you to share in my new year's resolution – to secure a more visible and vibrant presence for nurses in this work.

About the Author

Lynn M. Nagle, Associate Editor

References

Canada Health Infoway. 2009. Making Health Information Work Better for Canadians. Infoway's 2009–2010 Corporate Business Plan. Retrieved January 4, 2010. <http://www.infoway-inforoute.ca/lang-en/about-infoway/about/annual-reports-and-business-plans>.

Ministry of Health and Long-Term Care (MoHLTC). 2009. Health Outcomes for Better Information and Care (HOBIC). Retrieved January 4, 2010. <http://www.health.gov.on.ca/english/providers/project/nursing/nursing_mn.html>.

Nagle, L.M. 2007a. "Everything I Know about Informatics, I Didn't Learn in Nursing School." Canadian Journal of Nursing Leadership 20(3): 22–25.

Nagle, L.M. 2007b. "Clinical Documentation Standards – Promise or Peril?" Canadian Journal of Nursing Leadership 20(4): 33–36.

Nagle, L.M. 2008a. "Luddite or Luminary?" Canadian Journal of Nursing Leadership 21(1): 23–26.

Nagle, L.M. 2008b. "Considering the Human Factor." Canadian Journal of Nursing Leadership 21(2): 34–37.

Nagle, L.M. 2008c. "What Else Does the Box Say?" Canadian Journal of Nursing Leadership 21(3): 22–25.

Nagle, L.M. 2009. "Be Careful What You Wish For." Canadian Journal of Nursing Leadership 22(2): 26–29.

Pringle, D. and L.M. Nagle. 2009. "Leadership for the Information Age: The Time for Action Is Now." Canadian Journal of Nursing Leadership 22(1): 1–6.

Technology Informatics Guiding Educational Reform (TIGER). 2009a. The TIGER Summit. Retrieved January 4, 2010. <http://www.tigersummit.com/Summit.html>.

Technology Informatics Guiding Educational Reform (TIGER). 2009b. Seven Key Pillars. Retrieved January 4, 2010. <http://www.tigersummit.com/Pillars.html>.

Technology Informatics Guiding Educational Reform (TIGER). 2009c. About TIGER. Retrieved January 4, 2010. <http://www.tigersummit.com/About_Us.html>.

Technology Informatics Guiding Educational Reform (TIGER). 2009d. Technology Informatics Guiding Educational Reform: The TIGER Collaborative Teams – Phase II Activities. Retrieved January 4, 2010. <http://www.tigersummit.com/9_Collaboratives.html>.

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