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Susan McBride, PhD, RN-BC, CPHIMS, FAAN
Mari Tietze, PhD, RN-BC, FHIMSS
Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN
Liz Stokes, JD, MA, RN
Eileen Weber, DNP, JD, BSN, RN, PHN

With the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, the United States, as of 2017, has achieved 95% saturation with electronic health records as a means to document healthcare delivery in acute care hospitals and guide clinical decision making. Evidence is mounting that EHRs are resulting in unintended consequences with patient safety implications. Clinical teams confront usability challenges that can present ethical issues requiring ethical decision-making models to support clinicians in appropriate action on behalf of safe, effective clinical care. The purpose of this article is to identify and address ethical issues raised by nurses in use of electronic health records. We provide a case scenario with application of the Four Component Model and describe a study of nurse experiences with the EHR. The nursing Code of Ethics, Nursing Scope and Standards, and Legal Implications are reviewed, and we conclude with recommendations and a call to action.

Citation: McBride, S., Tietze, M., Robichaux, C., Stokes, L., Weber, E., (January 31, 2018) "Identifying and Addressing Ethical Issues with Use of Electronic Health Records" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 5.

Key Words: electronic health records, ethics, ethical decision making, moral distress, usability, unintended consequences, patient safety, quality, Health Information Technology, Rest Four Component Model

Healthcare delivery in the United States (U.S.) is changing at a rapid pace to keep up with the ever-growing population health needs and for management of chronic diseases ( Healthy Aging Team, 2017). With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 ( U.S. Department of Health and Human Services, 2012), the United States, as of 2017, has achieved a 95% saturation with electronic health records (EHRs) as a means to document healthcare delivery in acute care hospitals and guide healthcare delivery clinical decision making ( Office of National Coordinator for Health Information Technology, 2017). Approximately 60% of U.S. office-based physicians have an EHR implemented and in use.

...in many respects, care has improved with use of technologies... Collectively, these trends impact nurses nationwide across all care settings. Studies have indicated that, in many respects, care has improved with use of technologies and, when meaningful use of EHRs is fully achieved and experienced by nurses, they are much more likely to be satisfied with the EHR ( McBride, Tietze, Hanley, & Thomas, 2017). Evidence is mounting that these same systems are also resulting in unintended consequences with patient safety implications, potentially contributing to provider moral distress ( Henry, Pylypchuk, Searcy, & Patel, 2016). Clinical teams often confront usability challenges that present ethical issues and require ethical decision-making models to support clinicians with appropriate action on behalf of safe and effective clinical care.

Clinical teams often confront usability challenges that present ethical issues... The purpose of this article is to identify and address ethical issues raised by nurses in use of EHRs. We provide a case scenario with application of the Four Component Model (FCM) ( Rest, 1986). To do this, a clinical case study will be presented, along with discussion of nurse experiences using the EHRs in a recent study ( McBride, Tietze, Hanley, & Thomas, 2015). Then, recommendations and a call to action are made based on the FCM in light of nursing practice standards, ethical issues, and where applicable legal issues.

...formulaic alerts can present challenges to clinical decision making... One strength associated with certified EHRs under the HITECH Act of 2009 for supporting patient safety and quality is that evidenced-based protocols can be reinforced by using clinical decision support (CDS). CDS is designed to trigger, or alert, the clinical team with the right information, through the right channels, to the right person, at the right time, for the right patient, via the correct route of the EHR or supporting technologies ( Osheroff et al., 2012). These same formulaic alerts can present challenges to clinical decision making for clinical teams working with an actual patient, raising practical and ethical considerations.

When examining ethical issues and applying frameworks to analyze a situation, clinical scenarios often help to ground discussions of problems in the day-to-day clinical care that commonly occur in healthcare delivery. The following case presents a scenario for applying a framework to address ethical concerns that nurses have raised regarding the function of some EHRs.

She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema... Nancy has worked in a busy community hospital emergency department (ED) for over ten years. She is caring for a patient that presents to the ED with the following:

sepsis suspected due to possible pneumonia

oxygen saturation 88% on 4 liters of O2 via nasal cannula

respiratory rate of 30

heart rate of 110

These symptoms trigger the EHR CDS alert for sepsis because the patient scored high on the hospital sepsis screening tool built within the EHR. The CDS fires alerts that prompt the ordering physician to fluid resuscitate the patient according to the Center for Disease Control guidelines for suspected sepsis. Nancy recognizes that not only does this patient have symptoms that could be evolving sepsis, but the EHR indicates the patient has previously been admitted for fluid overload from heart failure (HF). She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema because the patient also exhibits 2+ pitting edema and crackles in both lung bases.

The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. Nancy questions the doctor order for aggressive fluid bolus and relates her concern that the patient is not septic. She points out the history of HF, which creates a risk for fluid overload with the bolus. The physician agrees with the nurse but states, "just drip it in slow, otherwise if we don't follow protocol we may fall out of the sepsis quality metric for the hospital. I don't want to send this patient to the ICU and have it later determined to be a sepsis case that we didn't follow protocol on!"

[Nancy] feels very distressed but hopes for the best outcome for this patient. No order for a slow drip was noted in the EHR, with only a verbal instruction on a busy ED shift for a patient ready for transfer to the ICU. Nancy questions the appropriateness of the physician orders, but follows physician instructions. She feels very distressed but hopes for the best outcome for this patient. She subsequently reports the request by the physician to drip slowly in a verbal handoff to the ICU nurse who receives the patient. The ICU nurse, recognizing that the drip does not follow the EHR recorded order, opens up the drip according to the computer provider order entry (CPOE). The patient has respiratory arrest. The patient requires intubation due to flash pulmonary edema with a subsequent diagnosis of acute onset of exacerbated fluid overload, secondary to rapid administration of intravenous (IV) fluid bolus and complication of HF. The attending intensivist on duty determines that the patient does not have sepsis.

This case presents a scenario happening across the nation in terms of EHR triggered protocols that capture electronic quality measures, often tied to value-based purchasing payer models upon which the organization will be penalized in the event measures are not met. This case study illustrates evolving guidelines that require clinical teams to use critical thinking skills when presented with CDS or information within the EHR that is not aligned with the clinical judgment of the entire clinical team. Further, this case offers several ethical considerations for examination. The scenario also reinforces nurses' statements as reported in 2015 via the Texas Nurses Association-Texas Organization of Nurse Executives (TNA-TONE) statewide study on EHRs ( McBride et al., 2015). For example, the following was one of 352 statements by nurses about EHR experiences:

Yes, the documentation of "quality standards" has greatly improved, but patient care and patient safety has not. In fact nurses have to enter false information sometimes and work around the system (I use vendor X, Y and Z) and all have similar issues. I know first-hand of 2 sentinel events caused by the systems (X and Y). Also systems audits are being used to evaluate and discipline nurses; this is a big ethical issue as nurses are charting stuff for the wrong reasons/........creating a conflict of interest.

This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. We can also consider the distress that can occur when protocols/guidelines; clinical decision support systems; nurse-patient relationship; and clinical communications between and among teams conflict with a nurse's code of ethics.

As a result of the HITECH Act in 2009, the TNA Board of Directors formed a Health Information Technology advisory committee. This committee was to evaluate the changing health technology environment and make recommendations to the TNA Board regarding steps needed to prepare Texas nurses for the rapid uptake of technology in healthcare settings required by this legislation. The TNA Board joined with the Texas Organization of Nurse Executives (TONE) to create a statewide partnership with nursing leaders to address the impact of health information technology (HIT) on nursing in the state of Texas.

The TNA-TONE HIT committee was charged with examining how Texas nurses were impacted by newly implemented EHRs across the state and to establish baseline measures of nurse satisfaction to inform evidence-based improvement strategies. A statewide study was initiated to evaluate nurse perceptions about clinical information systems such as EHRs.

... analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas... Quantitative results from the statewide study indicated that nurses were 84% more likely to be satisfied when they reported high scores related to a meaningful use maturity sensitivity index (MUMSI). The MUMSI allowed for analysis that addressed differing levels of functional status, or maturity of the given EHR using the meaningful use (MU) measures as a proxy for maturity ( McBride et al., 2017). However, analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas (please note that we are using the terms "moral" and "ethical" interchangeably in accordance with the current literature). We believe the ethical issues, in particular, warrant further exploration and require models of decision making to support clinical interprofessional teams in appropriate decision-making and subsequent action.

In the Texas-based statewide study ( McBride et al., 2015), researchers elicited additional information to learn about experiences of nurses using EHRs with this open-ended statement: "We are interested in your feedback and anything we might not have covered, please provide any additional information you care to provide." Just over 30% (352 of 1,157 participants) provided written comments about their experiences.

A thematic content analysis of the narrative responses to the open text question was used to analyze the data. Texts were organized in a spreadsheet and reviewed systematically by two qualitative researchers from the TNA/TONE committee research subgroup to identify key concepts. The text narrative responses were then reorganized according to concepts and summarized into categorical statements. Further immersion and analysis of the categories by two researchers with informatics expertise resulted in a synthesis of comments within the categories that revealed several primary themes. These are noted in Figure 1.

A conceptual model that reflects the overall common concepts detected in the thematic analysis was developed by the research group and is also noted in Figure 1. Note that "Patient Safety and Quality" is a major theme, with a minor theme "documentation/legality." This suggested that practice challenges associated with patient safety and quality were experienced. We learned that these were reflected, among other ways, in the EHR-based documentation that varied from established interprofessional practice standards. Although the case study and the Texas nurses' comments reflected ethical issues raised by nurses, there are significant implications for the entire care team given the EHR is the primary means of interprofessional communication.
Figure 1. Major and minor themes related to qualitative study comments.
[ View full size]

A sampling of these comments is provided by categories in Table 1. They are grouped by category of content.
Table 1. Comments by Nurses about their EHR Experience

I have almost no training on the "System." I have to fumble around to do anything on this "System" and it is purely an accident when I do find what I need.

System was not designed by the people who would use it. It does not capture the data required by the state to successfully use it. We are unable to see any notes/assessments that we did not personally input. Very frustrating because we constantly have to do double work. Sometimes the canned responses to questions do not have the appropriate answer listed as an option, and the only way to complete the documentation is to go to another menu and enter a nurse's note. Our preop department uses entries in both the nursing module and the OR module, which necessitates constantly switching from one menu to another - time consuming and inefficient. The "copy/paste" function has made it easier for providers to not write new original assessments. Because most of the notes are copy and pasted, there are many discrepancies (on one line, the patient is intubated; on the next line of the same patient, the patient is on nasal cannula). It's made the notes semi-worthless. This system has quadrupled our workload. It is not accurate and orders tend to disappear. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. This system is difficult to view orders and communicate with others. Things do not work well. It takes several hours to get thru discharges due to links that do not work. With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active.

Our computers at times freeze inside the room. During am med pass, it is so stressful finding a good computer that does not freeze. Sometimes I have to go through 3-5 computers before finding one that works.

Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient.

The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action... The case scenario above provides an opportunity to explore a holistic framework, the Four Component Model ( Rest, 1986), to identify and address ethical issues in nursing practice. The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action: sensitivity, judgment, motivation, and action ( Rest, 1986; Robichaux, 2012; Robichaux, 2017; Rushton & Penticuff, 2007).

Ethical Sensitivity
Ethical sensitivity is described as our ability to recognize an ethical problem, the moral implications of our decisions, and how our actions affect other people ( Milliken, 2016). Its development depends on an understanding of the ethical nature of the role as an obligation of the nursing profession ( Milliken & Grace, 2017). In the case scenario, Nancy recognized that adhering to the EHR-triggered CDS guideline might result in a poor outcome. She may have also been aware of her accountability in the situation as stated in the ANA Code of Ethics for Nurses with Interpretive Statements, "Systems and technologies that assist in clinical practice are adjunct to, not replacements for, the nurse's knowledge and skill" ( American Nurses Association [ANA], 2015, p.16; hereafter referred to as Code of Ethics). Having practiced in the ED for ten years, Nancy may be respected by her nursing peers and physician colleagues and may question how her actions could potentially affect those professional relationships.

Ethical Judgment
Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty. The second component of the FCM is ethical judgment or decision-making, a deliberative process reflecting knowledge of ethical principles, theories, and codes. There are several models (see Table 2); most have elements that outline an approach to reaching a decision through identifying facts and considering specific questions related to ethical principles and/or virtue ethics and care ethics. Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty ( Grace, 2014; Milliken & Grace, 2017; Robichaux, 2017). Recognizing the potential harm of following the sepsis guidelines in a patient with suspected pulmonary edema, Nancy decides to share her concerns with the physician.
Table 2. Ethical Judgment/Decision-making Models
Ethical Motivation
All nurses want to be ethical and live in a manner consistent with their personal and professional values. Although they may recognize an ethical issue and be aware of their role-associated obligations, personal and/or institutional barriers may impede their motivation to act. The third component in the FCM, ethical motivation is the bridge between decision-making and action ( Robichaux, 2017).

Competing personal values... can impede motivation and action. Competing personal values such as protecting one's position or reputation can impede motivation and action. "Persevering to do the right thing" ( Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014, p. 14) can also be hampered by institutional barriers. Lack of supervisory support, fear of reprisal, and hierarchal decision-making may silence nurses' moral voices ( Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013). These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. Wolf et al. ( 2016) described the moral distress of ED nurses who are unable to meet their role obligations to provide safe and effective patient care in such environments.

The stress felt by Nancy in the presented ED case scenario is an example of this type of moral distress. Specific themes reflected in the case scenario and noted by Wolf and colleagues' ( 2016) qualitative investigation relate to moral distress due to overemphasis on documentation, tasks, and metrics at the expense of patient care, as well as role conflicts resulting from hierarchical decision making. These same issues are reflected in a number of comments in Table 1 (e.g., overemphasis on documentation and measurement creating inefficiencies and a distraction to patient care).

Ethical Action
Nancy questions the physician's decision to follow the sepsis quality metric and not write an order in the EHR for slow intravenous fluid administration. She verbally reports this information to the receiving ICU nurse and hopes "for the best outcome" for the patient. Could additional actions have been taken? Developing moral courage may assist in overcoming personal and institutional barriers to further nurse advocacy. Individuals with moral courage have developed skills of effective engagement and "willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way" ( Lachman, 2007, p. 131). Moral courage can also be "learned, practiced, and mentored" ( Hawkins & Morse, 2014, p. 268). When moral courage and ethical action are thwarted by constraints outside the nurse's control, moral distress can result.

Nurses experience moral distress, a concept first highlighted by Andrew Jameton in 1984, when they "know the right thing to do while being in a situation in which it is nearly impossible to do it." ( Jameton, 2017, p. 617). Jameton described three components that can apply to the pain expressed by the nurses that contributed to the Texas study: knowing what is right, being in a situation that constrains acting on that knowledge, and the psychological distress resulting from that inability to do the right thing ( Jameton, 2017).

It may be challenging to remember what actions to take when encountering a situation that requires moral courage. It may be challenging to remember what actions to take when encountering a situation that requires moral courage ( Lachman, 2010; Lachman, Murray, Iseminger, & Ganske, 2012) Lachman et al. ( 2012) have developed a useful mnemonic, CODE ( Courage; Obligations to honor; Danger management; Expression), that reminds nurses of their ethical obligations and actions as detailed in the nursing Code of Ethics ( ANA, 2015). The CODE mnemonic strategy helps nurses to recall these actions and includes ways to overcome fear and reluctance to speak up including reflection, reframing, and assertiveness skills.

The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics. The Code of Ethics states, "Patients' rights are the primary factor in any decisions regarding personal information, whether from or about the patient. These rights of privacy and confidentiality pertain to all information in any manner that is communicated or transmitted" ( ANA, 2015, p. 10). While nurses are aware of this ethical obligation in relation to the EHR, they may be less familiar with additional ethical issues inherent in its use and development. The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics. From cardiopulmonary resuscitation (CPR) to genetic engineering, the creation and use of an innovative tool may surpass the knowledge and resources required to ensure an ethical and appropriate use ( Goodman, 2015).

The current and potential positive impact of the EHR on quality care is not disputed. However, ethical issues surrounding dominance of institutional priorities over autonomous patient-centered practice and care driven by application of decision-support, templates, and/or clinical practice guidelines (CPGs) have been documented ( Lown & Rodriguez, 2012; McBride, Tietze, Hanley, & Thomas, 2015; Sulmasy, López, & Horwitch, 2017). Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship ( de Ruiter, Liaschenko, & Angus, 2016; Rathert, Mittler, Banerjee, & McDaniel, 2016).

The centrality of the patient-nurse relationship to the nursing discipline is reflected in the interpretive statement, "The nurse's primary commitment is to the recipients of nursing and health care services" ( ANA, 2015, p. 5). Effective communication is vital to this relationship, and the EHR may have a negative effect. Research suggests that it can become a "third party "in the process, potentially reshaping the interaction, changing the patient narrative, and diverting nurse attention away from the patient ( Rathert et al., 2016).

Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship. The use of computers and communication technologies will impact more lives in the 21st century than any other technology, including stem cells, transplants, and nanomedicine ( Goodman, 2015). As the largest group of healthcare professionals who document, more than any other discipline in acute care organizations, ( OʼBrien, Weaver, Settergren, Hook, & Ivory, 2015) nurses are at the forefront to ensure that the EHR is patient-centered and contributes to safe, ethical practice.

As indicated in the case scenario and the study findings, the use of the EHR can result in a unique set of ethical and legal challenges. Nurses must be prepared to face these challenges and recognize the requirements of state and federal law, workplace policies, and obligations of the profession. A study in 2006 revealed that nurses spent a majority of indirect nursing time documenting in the EHR, demonstrating the critical necessity of proper usage to satisfy quality of patient care ( Kim, 2006). The Scope and Standards of Nursing Practice ( ANA, 2015) establishes the standard of practice for registered nurses in the United States, noting "Nurses must document relevant data accurately and in a manner accessible to the interprofessional team" ( ANA, 2015, p. 54). Documentation in the nursing record must follow principles of "factuality, accuracy, completeness, timeliness, organization, and compliance" ( ANA, 2015, p. 270). Documentation must be clear and accurate to provide a basis for the contribution of nurses to patient outcomes and the viability of healthcare organizations ( ANA, 2015).

Documentation that fails to meet these principles can result in undesirable outcomes for the nurse, patients and families, or for the healthcare organization ( ANA, 2015). Nursing documentation, electronic or handwritten, are legal documents that can, under some circumstances, be used in legal proceedings. Nurses maintain competence regarding the legal significance of documentation and therefore must demonstrate legible and comprehensive reporting ( Larsen, 2012). Some EHR systems are designed as templates or 'fill-in' instruments, which allow for auto-population of lab results or other critical information ( Sittig & Singh, 2011). The auto-fill function can result in unintentional documentation of a clinical finding that may not be within a nurse's clinical purview ( Sittig & Singh, 2011). Once documentation has been electronically recorded and signed by the nurse, the liability of that acknowledgement is not clear.

A number of healthcare organizations have implemented 'copy and paste' policies for documenting in the EHR. The copy and paste functionality includes copying, pasting, cloning, auto-filling, carrying forward, replicating data and reusing content from one section to another within the EHR ( Scruth, 2014). The copy and paste phenomenon has caused significant debate from those who argue its necessity for time efficiency weighed against the significant risk of inaccuracy and patient safety errors ( Harrington, 2017). Copy and paste functionalities can result in unintentional reliance on outdated or inaccurate clinically relevant information, such as treatment plan; distracted notes; diagnostic biases; incorrect information for a specific patient visit; and expired patient symptoms and assessments ( Scruth, 2014; Weis & Levy, 2014). These practices can result in timeliness issues or time-related accuracy of documentation in any EHR.

... healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry. EHRs are designed to facilitate easier provider order entry and have been shown to reduce prescription errors ( Scruth, 2014). They have tremendous potential to improve efficiency of healthcare delivery and improvement of quality patient care. However, healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry ( McBride et al., 2017; Wolf et al., 2016). In the early 1990s 'charting by exception' was an acceptable method to decrease charting in nursing ( de Ruiter et al., 2016). Historically, it was assumed that all standards of care were met unless documented otherwise. However, with the introduction of the EHR, complete documentation requires charting of all clinical assessments, care plans, interventions, and outcomes requiring more time for documentation ( de Ruiter et al., 2016).

As a result of time constraints and usability issues, nurses have reportedly been intentionally entering false information to bypass or 'work-around' EHR systems ( McBride & Tietze, 2017). Although privacy, security, and confidentiality have been identified as three main areas of concern when using EHRs, little attention has focused on false entries, work-arounds, or system bypasses ( Ayatollahi, Mirani, & Haghani, 2014; CMPA, 2015).

...a false entry into an EHR can follow a patient for years. Additionally, alert fatigue and clinical information overrides must be addressed within the organization. Legal concerns over notification of federally regulated drug interactions, through pop-ups or alerts, can be overwhelming or desensitizing to the nurse ( Sittig & Singh, 2011). Overriding content in what is often an undesirable system design can result in misinformation in charting that can have detrimental effects on the nurse, patient, and healthcare organization. For example, a false entry into an EHR can follow a patient for years. The patient is likely unaware of the false entry, but subsequently applies for health or life insurance. The patient may be denied insurance coverage based on a one-time false entry that was replicated over time.

We conclude with a call to action for interprofessional teams, associations, industry, and others to collaboratively address these issues on behalf of the health and safety of the nation, and equally as important, the health and well-being of the healthcare workforce. To do that, the authors suggest the following recommendations to address challenges with EHRs. These recommendations may help mitigate ethical and legal issues arising as a result of the massive uptake of technology that has resulted in the digital age of healthcare delivery.

Nurses must have a seamless mechanism for reporting EHR challenges... Nurses face time constraints, overstaffing, and unfamiliarity with EHR systems on a daily basis. Healthcare organizations must have structures in place at the unit, management, and administrative levels to facilitate effective use of EHRs in nursing practice. For example, some EHR contracts have "hold harmless clauses" which restrict nurses' ability to effectively and timely report EHR problems ( Sittig & Singh, 2011). Nurses must have a seamless mechanism for reporting EHR challenges (e.g., inappropriate or cumbersome alerts) without an arduous process or fear of reprisal. This type of support could potentially mitigate the moral distress noted in the case scenario.

Culture of Safety
Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. All nurses are "responsible for contributing to a moral environment" in healthcare ( ANA, 2015, p. 24). Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. The ANA Scope and Standards of Practice for Nursing Administration (2009) cites the obligation of nurse administrators to advocate for practice that reflects the Code of Ethics ( ANA, 2015). It specifies duties that nurses in leadership and managerial roles have, particularly in transformational and servant leadership frameworks, to open communication and to act "entirely on the behalf of those led" ( ANA, 2009, p. 8) to identify problems and integrate ethical provisions in all areas of practice. Nurses in administrative roles should promote a culture of safety in their settings that include reducing the risk of harm arising from inadequate EHR design, and usability ( ANA, 2009).

Studies have shown that nurses with one year or less in practice demonstrate almost 70% more timely charting than nurses with more years of experience ( Ahn, Choi, & Kim, 2016). This emphasizes the need for continuing education for novice and expert nurses in EHR management and documentation. Informatics specialty nurses and advanced practice nurses can serve as leaders to assess and research documentation for timeliness and accuracy, along with providing continuing education on a frequent basis ( Scruth, 2014). Education about principles of documentation and competence in specific EHR system usage is needed to foster nurse mastery and development to successfully improve health outcomes ( Goodman, 2015).

Awareness of Support of Interprofessional Imperatives
Guidelines and best practices, such as the American College of Physicians position paper on clinical documentation ( Kuhn, Basch, Barr, & Yackel, 2015), ANA ( 2015) position statement on Privacy and Confidentiality,and American Nursing Informatics Association ( 2015) position statement on Addressing the Safety of Electronic Health Records are critical to ensuring that nurses are able to efficiently and appropriately meet principles of documentation. The American Health Information Management Association ( AHIMA, 2011) Code of Ethics has 11 principles with interpretive statements, referred to as guidelines, that seem to underscore the importance of practices that stand in stark contrast to the experiences of nurse participants in the Texas nursing research ( McBride et al., 2015). The AHIMA principles cite the primacy of accuracy, avoidance of conflicts of interest, and similar to the ANA code, "respect [for] the inherent dignity and worth of every person" ( AHIMA, 2011, 11). Under this AHIMA principle, the noteworthy guideline to "ensure all voices are listened to and respected" ( AHIMA, 2011, 11.4) demands that health information managers not only welcome input from nurses who find the technological determinism of EHRs violates ethical practice and clinical judgment, but also seek out that input.

... the patient's story of his/her illness may be lost to the goal of generating standard data points that, in turn, trigger algorithms and practice recommendations. For care characterized by "screen-driven information gathering" ( Lown & Rodriguez, 2012, p. 393) the patient's story of his/her illness may be lost to the goal of generating standard data points that, in turn, trigger algorithms and practice recommendations ( Brown, 2015). This computational capacity may establish EHR information as authoritative, potentially displacing work processes critical to nurse-patient interaction.

As evidenced in the study themes and the case scenario presented, critical thinking may be hindered and experiential knowledge devalued ( Campbell & Rankin, 2017). Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention ( Campbell & Rankin, 2017; Lown & Rodriguez, 2012; Sulmasy et al., 2017). Systems and technologies such as EHRs that assist in clinical practice are adjunct to, not replacements for, nurse knowledge and skill ( ANA, 2015).

Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention. Finally, as reflected in the Texas study and clinical scenario, current technology in the healthcare industry often presents challenges with usability, design, implementation, and failure to adequately support clinical teams. This results in ethical situations often associated with feelings of moral distress. Application of the FCM can assist clinical teams to explore and potentially resolve these issues. Additionally, the authors recommend further research into the moral distress noted in emerging evidence, including the TNA-TONE statewide study and the case scenario presented. As such, the healthcare industry has an imperative to identify and address ethical issues with use of EHRs.

The authors wish to acknowledge the support for the study by Texas Nurses Association (TNA) and the Texas Organization of Nurse Executive (TONE). From the beginning in 2010 when the TNA Board of Directors resolution was passed, the two organizations created the partnership that provided cumulative guidance, funding, and dissemination efforts throughout the years. Specifically, we would like to acknowledge the staff of these organizations, the dozens of volunteer committee members who have served, and the report writing sub-committee of Susan McBride, Mary Anne Hanley, Cindy Zolnierek, Laura Thomas, Mari Tietze, and Huaxin Song. Finally, we acknowledge the many subject-matter experts who, through numerous focus groups, helped yield the final surveys. Please see the TNA/TONE HIT Web site for the long list of names.

Dr. McBride is a Professor at the Texas Tech University Health Sciences Center School of Nursing whose research focus is on methods development for implementing, evaluating and utilizing health information technology to address patient safety, quality and population health. Dr. McBride was the Principal Investigator for a Texas Statewide Study of Nurses Satisfaction with their electronic health records. She is a professor with teaching responsibilities supporting graduate courses in statistics, informatics, and epidemiology. She is a Fellow in the Academy of Nursing and sits on the Information Technology and Informatics Expert Panel.

Dr. Tietze is a Professor at the Texas Woman's University (TWU) College of Nursing, teaching informatics courses focused on interprofessional collaborative practice and Director of the Graduate Certificate in Interprofessional Informatics program. Dr. Tietze is the Doswell Endowed Chair for Nursing Informatics aimed at advancing nursing informatics at TWU. Since 2010, she has been the co-chair of the Texas Nurses Association/Texas Organization of Nurse Executives Health Information Technology committee to represent nurses' experiences related to information technology use in their practice of patient care delivery. Research focus is telehealth with a telemedicine, remote management and mobile health component. Dr. Tietze has been certified since 2000 by ANA in Informatics Nursing.

Dr. Robichaux is an Adjunct Assistant Professor at University of Texas Health; San Antonio, Texas and The University of Mary in Bismarck, North Dakota. She has taught ethics at the undergraduate and graduate levels and conducted research on moral distress and ethical climate among other issues. Catherine was a member of the Steering Committee to revise the Code of Ethics and is currently a member of the ANA Ethics Advisory Board.

Ms. Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights. She worked for several years as a critical care nurse and later received her law degree. She worked as a consultant for the D.C. Board of Nursing interpreting professional ethics provisions and recently completed her masters in bioethics. Her leadership is demonstrated through various charitable roles. Liz serves as an Associate Editor for the Journal of Bioethical Inquiry and is a volunteer with the D.C. Bar Association. She is currently an American Academy of Nursing Jonas Health Policy Scholar.

Dr. Weber is a nurse attorney and Clinical Assistant Professor at the University of Minnesota School of Nursing, where she teaches ethics, leadership, and public policy in the context of a continuum of interprofessional healthcare. She founded and leads the Upper Midwest Healthcare Legal Partnership Learning Collaborative. She serves on the American Nurses Association Center for Ethics and Human Rights Advisory Board and the University of Minnesota Medical Center (Fairview) ethics committee.

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© 2018 OJIN: The Online Journal of Issues in Nursing

Article published January 31, 2018

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Identifying and Addressing Ethical Issues with Use of Electronic Health Records

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Susan McBride, PhD, RN-BC, CPHIMS, FAAN Mari Tietze, PhD, RN-BC, FHIMSS Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN Liz Stokes, JD, MA, RN Eileen Weber, DNP, JD, BSN, RN, PHN With the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, the United States, as of 2017, has achieved 95% saturation with electronic health records as a means to document healthcare delivery in acute care hospitals and guide clinical decision making.

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What are the General Principles in Informatic Ethics?

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What are the General Principles in Informatic Ethics?

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·     Information-Privacy and Disposition

·     Principle of Openness

·     Principle of Security

·     Principle of Access

·     Principle of Legitimate Infringement

·     Principle of Least Intrusive

·     Principle of Accountability

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7 Ways to Use Infographics in Healthcare + Templates

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Exploratory analysis: what do you do to understand the data

Explanatory analysis: involves the specific subject you want to explain and a specific story to tell.

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Descriptive: describes current situations and problems

Predictive: simulation and modeling to identify trends of actions taken

Prescriptive: optimizing clinical, financial, and other outcomes

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Health Insurance Portability and Accountability Act

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Health Insurance Portability and Accountability Act

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Privacy rule that mandates to de-identify data by removing 18 different identifiers.

This act helps to protect privacy and security measures in health care. After the addition of HIPPA, the ARRA and the HITECH Act were created.

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I found this video to be helpful to breakdown the basics of the “Swiss cheese Model”. This model can be used in risk analysis and risk management in healthcare.

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Can gamification and behavioral economics be used to produce healthier behaviors in high-risk patients? Experts see a significant opportunity.

Already, many industries use game elements that leverage behavioral science to drive desired customer behaviors. Think airline loyalty programs that award points and status for miles traveled. Such programs have been proven to engage customers and have a meaningful impact on behaviors.

Gamification that uses behavioral economics principles is now coming to healthcare. Leading healthcare thinkers and organizations are exploring how to use gamification to engage patients and help them adopt healthier behaviors-like taking their drugs, losing weight, or exercising more.

In this HBR webinar, Mitesh Patel and Kevin Volpp will describe how most current health and fitness apps fail to effectively incorporate game elements in their design. They will also share examples of studies and interventions using gamification that show significant promise.

Patel and Volpp-who are experts on health incentives, behavioral economics, and "nudge" theory-will detail specific best practices in gamification and behavioral economics that can influence patient behavior. These practices include techniques to effectively engage and motivate high-risk patients like:

Opt-in/out-out framing

Personalized goal setting

Pre-commitment pledges

Social incentives

They provide case studies of gamification programs that have produced significant behavioral changes among high-risk patients, leading to dramatic improvement in health results.

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How Gamification Can Change Health Behaviors

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Featuring Mitesh Patel, MD, and Kevin Volpp, MD, both professors at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania.

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What's the news: Patients and physicians who have come to see the immense clinical value of telehealth throughout the COVID-19 pandemic can breathe a sigh of relief that access to this vital mode of care will continue for at least another five months after the Biden administration declares an end to the nation's public health emergency (PHE).

The provision is one of many related to health care included in the massive, $1.5 trillion spending bill-called the Consolidated Appropriations Act, 2022-that was passed last week and garnered headlines for including $13.6 billion in emergency aid for Ukraine as it struggles to fend off a brutal invasion from Vladimir Putin's Russia.

"Congress has taken a crucial step in starting a revolution in patient access. The AMA aims to continue being a partner in moving it forward," said AMA President Gerald E. Harmon, MD. "The dramatic increase in adoption of telehealth that occurred in 2020 has allowed medical care that combines in-person and virtual services to become the new standard of care. This new legislation guarantees that patients with Medicare will continue to benefit from this important innovation in health care delivery."

Why it's important: Many of the telehealth flexibilities that have helped dramatically improve patient access to care are temporary and limited to the duration of the COVID-19 PHE, and they affect both public health programs and private health coverage. The PHE must be renewed every 90 days, and is set to expire April 16. It is expected the PHE will be renewed for another 90 days, with a mid-July expiration date.

This puts doctors and health care organizations in the position of having to weigh the costs of investing in the technological and clinical infrastructure needed to maintain telehealth programs against the possibility that Congress may ultimately decide against supporting the permanent expansion of telehealth coverage that is so badly needed.

The AMA and a vast array of more than 300 other health care organizations urged congressional leaders to take this step as a way of "facilitating a pathway to comprehensive permanent telehealth reform that would provide certainty to beneficiaries and our nation's health care providers while providing sufficient time for Congress and the administration to analyze the impact of telehealth and patient care."

Prior to the pandemic, Medicare beneficiaries needed to be physically located in a rural area to access telehealth services, thus precluding urban and suburban patients from receiving the same benefits of virtual care. In addition, rural beneficiaries still needed to travel to an "originating site"-essentially another health care facility-outside of the home to access telehealth services.

"For decades, the AMA has recommended permanently removing the geographic and originating-site restrictions. Likewise, the AMA pushed to preserve the existing telehealth flexibilities since the COVID pandemic swept the country," Dr. Harmon said. "It's refreshing to see Congress agree. As patients take advantage of these changes and health access is broadened, we are hopeful that Congress will see the wisdom of making these changes permanent."

In addition to keeping the telehealth flexibilities in place for 151 days after the PHE ends, the new law also calls on the Medicare Payment Advisory Commission to issue a report on telehealth use by June 15, 2023.

"Telehealth has huge potential to expand access to high-quality virtual care for all Americans," says the letter the AMA and other organizations sent to Congress earlier this year. "Following the 2022-2023 evaluation period, all committees of jurisdiction will have at their disposal the necessary data to pursue evidence-based policymaking and take up comprehensive and permanent telehealth reform in a bipartisan manner."

Other notable health care provisions in the Consolidated Appropriations Act, 2022, will:

Give the Food and Drug Administration authority over products such as synthetic nicotine that contain nicotine but don't come from tobacco.

Train health professionals to improve prenatal care, labor care, birthing and postpartum care for patients from historically marginalized racial and ethnic groups, including with respect to perceptions and biases that may affect the approach to-and provision of-care.

Establish or continue evidence-based programs to deliver integrated health care services to pregnant postpartum women to reduce adverse maternal health outcomes and pregnancy-related deaths.

Improve rural maternal and obstetric care data, and establish rural collaborative improvement and innovation networks to improve maternal and infant health outcomes.

Extend the schedule 1 categorization of fentanyl-related substances under the Controlled Substances Act.

Boost the federal medical assistance percentage (FMAP) for Puerto Rico to 76% for Jan. 1-Dec. 13, adding $200 million to the island's Medicaid allotment as long as they ensure physicians and other health professionals are paid 70% of Medicare Part B rates.

Extend the 83% FMAP for American Samoa, the Commonwealth of the Northern Mariana Islands, Guam and the U.S. Virgin Islands through Dec. 13.

Learn more: The AMA fielded a survey on telehealth use at the end of 2021, and you can learn about the results in detail by attending this March 31 AMA STEPS Forward™ Telehealth Immersion Program webinar.

Meanwhile, the AMA telehealth quick guide covers practice implementation, policy, coding and payment, and other helpful resources for physicians.

Essential Tools & Resources

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Telehealth flexibilities assured for the bulk of 2022

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What's the news: Patients and physicians who have come to see the immense clinical value of telehealth throughout the COVID-19 pandemic can breathe a sigh of relief that access to this vital mode of care will continue for at least another five months after the Biden administration declares an end to the nation's public health emergency (PHE).

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-Primary care

-Speciality Care

-Remote patient monitoring

-Consumer medial and health information

-Medical education

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I found this video very helpful to get an breakdown of what health information exchange is. Some important take aways I got from this video include: patient rights are protected by state and federal laws, the ability for patients to opt out of sharing with the HIE, and the specific protection for substance use programs.

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What is Health Information Exchange (HIE)?

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·     Cost

·     Access

·     Quality

·     Safety

·     Efficiency of care delivery

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Recently, electronic health records have come to the forefront of medical reforms. Electronic health records (EHRs) are a digital version of a patient's medical history that organizes relevant clinical data in real-time to organize and improve the quality of care. Both Congress and the American Medical Informatics Association have reported that EHRs could play a key role in the future of personalized health care.

Personalized health care is an overarching framework for care that unifies predictive technologies with an engaged patient to coordinate care to promote health and prevent disease. Establishing widespread use of EHRs can help physicians keep track of medical advances, utilize appropriate treatments and prescriptions for patients, and coordinate with a patient's whole medical team, regardless of location. They also provide a way to track overall health outcomes, as well, enabling medical teams to determine the most effective treatments and improve overall quality of care.

Since 2009, there has been a concerted effort from the U.S. Department of Health and Human Services (HHS) to improve health information technology, with emphasis placed on integrating EHRs into health care delivery across the country. However, there are still significant barriers to overcome before EHRs can fulfill their potential to positively impact the health care system.
Senator Elizabeth Warren leads a hearing on current problems and the future potential of EHRs.
The Senate Health, Education, Labor, and Pensions Committee has led recent efforts to improve health I.T. and to identify and correct issues in electronic health records, with special focus on the recent Medicare and Medicaid EHR incentive programs. The Committee has set a goal of having a comprehensive network of universally compatible EHRs in the United States by 2020.

The American Medical Informatics Association's Electronic Health Records in 2020 task force released a report in May of 2015 detailing the current status of EHRs in the United States. The report details current challenges in the adoption of EHRs, including but not limited to the incompatibility of separate health systems' EHR software, the security of data collected, the simplicity of the record itself, and the administrative burden of data entry on clinicians.

Despite these obstacles, the report notably acknowledges the importance of a strong system of electronic health records for both patients and providers as we move towards developing a more coordinated, proactive, and personalized approach to care. Including patient-generated data, population data and community contexts into an EHR will spur development of new care delivery models, improve population health, aid in the development of precision medicine and support other healthcare transformations.

Effective use of EHRs can lead to concrete improvements in health care quality; studies have demonstrated that giving patients access to their electronic medical record is associated with desirable health outcomes. This suggests that the EHR can also be a valuable tool for engaging patients in their care and improving the skills, knowledge, and abilities to self-manage their health. This means that it is essential for EHRs to offer a level of simplicity and usability. As providers work to integrate more personalized models of care into practice, the technology that supports these fundamental changes must be easy to integrate into daily life.

Click here to view the full AMIA EHR task force report.

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The Rising Importance of Electronic Health Records - Duke Personalized Health Care

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Recently, electronic health records have come to the forefront of medical reforms. Electronic health records (EHRs) are a digital version of a patient's medical history that organizes relevant clinical data in real-time to organize and improve the quality of care....Read more ›

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The AMA continues to advocate to make the MU program more workable for providers by asking to:

Establish more reasonable reporting requirements, measurements thresholds, and overall flexibility to providers who participate in this.

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The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program-also known as Meaningful Use or MU-initially provided incentives to accelerate the adoption of electronic health records (EHRs) to meet program requirements.

Now, physicians who fail to participate in MU will receive a penalty in the form of reduced Medicare reimbursements. Physicians must use certified electronic health records technology (CEHRT) and demonstrate meaningful use through an attestation process at the end of each MU reporting period to avoid the penalty.

The AMA is encouraging all physicians subject to the 2015 Medicare MU program to apply for a hardship exception. CMS has stated that it will broadly accept hardship exemptions because of the delayed publication of the program regulations. Applying for the hardship will not prevent a physician from earning an incentive. Applications for physicians are due July 1, 2016.

CMS developed a program that requires physicians using CEHRT to capture, exchange and report specific clinical data and quality measures. The program, which began in 2011, evolved over the course of 3 stages:

Stage 1 established the base requirements for electronic capturing of clinical data.

Stage 2 encouraged the use of EHRs for increased exchange of information and continuous quality improvement at the point of care.

Modified Stage 2, released in October 2015, consolidated Stages 1 and 2 into a new program. These are the current requirements all physicians should follow. While some changes were made to reduce the complexity of the measures, many of the objectives were carried over from Stage 2.

Summary of 2015-2017 Meaningful Use (MU) Final Rule (PDF) (members only)

The requirements for Stage 3 have been published by CMS. Starting in 2018, all eligible physicians will be required to participate in Stage 3.

Summary of the Meaningful Use Stage 3 and 2015 certification rules requirements (PDF) (members only)

MU will eventually become part of the Medicare Merit-based Incentive Program.
Understanding Medicare's Merit-based Incentive Payment System (MIPS)
Physicians participating in MU for the first time in 2016 will not qualify for any MU incentive payments but will be subject to a penalty if they do not participate.

All physicians participating in MU in 2016 must demonstrate the 10 new Modified Stage 2 requirements.

Modified Stage 2 requirements (PDF)

CMS has developed a webpage on 2016 Program Requirements with detailed and downloadable lists of each requirement.
CMS 2016 program requirements
CMS has also posted their presentations on Modified Stage 2 and Stage 3 requirements from the HIMSS 2016 Annual Conference.
CMS presentations on Modified Stage 2 and Stage 3 requirements
To help physicians meet MU requirements, the AMA compiled tip sheets on some of the more complex measures.

Patient view, download and transmittal of health information (PDF) (members only)

Transition and summary of care (PDF) (members only)

Security Risk Analysis (PDF) (members only)

Part of participating in MU involves using technology certified by the U.S. Department of Health and Human Services (HHS). Certified technology includes both complete EHR systems and individual modules. Physicians can either purchase a comprehensive certified package from a single vendor or certified components from different vendors.

Physicians should ask their vendor about certification plans if they are unclear whether their EHR technology or module(s) are certified for use in the incentive program. Physicians can verify whether the equipment is certified at the Office of the National Coordinator for Health IT's (ONC) website.
Office of the National Coordinator for Health IT's (ONC)
For additional information about 2015 EHR certification criteria see ONC's final certification rule.
2015 EHR Final Certification Rule
Together with the AMA, AmericanEHR Partners provides the ability for a physician to rate or comment on EHR systems. There are also message boards that facilitate group discussion and allow users to refine their search for product information by using criteria that are most relevant to them, such as practice size and specialty.
AmericanEHR Partners
All ratings and discussion topics come from verified members who must register with AmericanEHR Partners and are compared against a physician master file, ensuring real users are discussing and rating real products.

Usability is the capacity for an individual to learn and easily use an object. Both utility (how well a system handles the work a user must do) and ease-of-use are factors in usability.

The AMA strongly believes that EHR technology should:

Facilitate a physician's practice

Improve patient care

Enhance care coordination, practice efficiencies and processes

Support decision-making, not circumvent the need for critical thinking

To improve patient care, EHRs and other health technology must work well for the people who use them. Unfortunately, the swift implementation of EHR technology compelled physicians to purchase tools not yet optimized for patients or doctors. As a result, EHR technology can often impede efficient care by making it difficult to find or understand what clinicians need. Sometimes the technology may be challenging to use effectively, efficiently and safely.

The AMA believes that the addition of user-centered design (UCD) in the development of EHR products can improve usability and increase physician satisfaction with EHRs. This process focuses on analyzing and incorporating user requirements from the beginning of the development cycle. The AMA continues to work with key EHR-industry stakeholders and advocate that ONC include robust UCD when certifying technology.
Federal and State Correspondence Finder
However, EHR design is also heavily influenced by the federal requirements for MU and certification. While there are federal requirements on EHR usability, the design priority of EHR vendors continues to be meeting MU objectives, not the needs of physicians and patients. To help elevate this concern, the AMA worked with MedStar Health to identify issues with EHR certification and the incorporation of better UCD principles in the design of health IT products.

AMA and MedStar Health partner to drive improvements in EHR usability

As part of both HIPAA and MU requirements, physicians must conduct or review a security risk analysis at least once during each program year. A practice's size, complexity, capabilities, risk and cost are used to determine the proper methodology to meet this requirement. Conducting this analysis can provide insight into the vulnerabilities in a practice's heaIth IT. It is important to note that a health IT system is typically larger than just EHR.

The first step in protecting a practice and patients' health information from cyber attacks is evaluating a system's security. The rules for a risk analysis are not prescriptive; a number of different tactics can achieve compliance. The AMA has several free resources in the AMA Education Center for AMA PRA Category 1 Credit™ to help physicians build tailored compliance processes.

Additionally, the HHS has materials to help small-to-medium-sized practices become compliant, HHS EHR contracts: Key contract terms for users to understand. (PDF)

The AMA continues to advocate for making the MU program more workable for physicians by asking CMS to establish more reasonable reporting requirements, measurement thresholds and overall flexibility so that all physicians who want to participate are able to do so. Below are links to the most recent comments and letters to the administration and Congress.

As a result of significant AMA advocacy, CMS made several changes to the Stage 2 requirements, reducing the number of overall requirements and including exceptions to certain measures.

Following years of advocacy by the AMA, the CMS has removed the computerized physician order entry (CPOE) and clinical decision support (CDS) measures from the Medicare MU program and the ACI component of the Quality Payment Program (QPP). However, the Medicaid MU program continues to include CPOE and CDS measures.

While CPOE and CDS functionality will still be included in EHRs, CMS will no longer require a certain number of orders, that a physician enter the orders, and that physicians implement a certain number of CDS tools. This means that as of Jan. 1, 2017, physician practices are free to develop policies around CPOE and CDS in ways that blend with their workflows and improve care.

AMA letters

What to do if you are audited

The AMA has received a number of complaints and concerns associated with physicians undergoing an MU audit (currently 5 to 10% of eligible professionals) and is working to improve this process. Physicians should communicate any issues to the MU audit contractor:

Peter Figliozzi Figliozzi & Company, CPAs P.C. 585 Stewart Avenue Suite 416 Garden City, New York 11530[email protected] (516) 745-6400 ext. 302

The biggest issue physicians have faced in an audit was demonstrating the "yes/no" requirements that call for attestation proving the security risk analysis was successfully met. To help with the process, CMS posted information online and provided the following:

Related Links

CMS has an informal appeals process for those denied an EHR incentive payment, determined to be ineligible for the program, or given an unfavorable audit decision. Physicians looking to appeal an adverse decision should contact their state Medicaid Agency for information about filing an appeal. Under the CMS appeals process, physicians must file a claim and submit necessary documentation by the following deadlines:

Failed Audit Meaningful Use: 30 days from the date of the adverse audit determination letter

Failed Reporting Meaningful Use: March 31

Eligibility: March 31

All appeal decisions are final. More information on the MU appeals process can be found on the CMS website.

CMS appeals - If you have been denied an EHR incentive payment, you can appeal the decision.

The HHS Office of the Inspector General (OIG) and CMS published companion rules that allow physicians to accept donations of almost free EHR technology (must pay at least 15% of the cost of the technology) from certain health care entities without violating Stark and anti-kickback rules.

HHS Office of the Inspector General (OIG) - Exception for certain electronic health records arrangements (PDF)

CMS published companion rules - EHR safe harbor under the Anti-Kickback Statute; final rule (PDF)

The exception/safe harbor was scheduled to end on Dec. 31, 2013, but due to AMA advocacy, HHS extended the time through 2021. While the AMA pushed for a permanent exception, the extension brings welcomed relief for physicians continuing to struggle with the high cost of implementing EHR technology. The rules also made several other notable changes:

Excluded labs from the types of entities that may donate EHR technology

Updated the definition of what type of software is considered interoperable for the purposes of donations

Clarified the requirement prohibiting any action that limits or restricts the use, compatibility or interoperability of donated items or services

Removed from the exception the requirement related to electronic prescribing capability

HHS accepted the argument that labs should be removed from the types of entities permitted to donate EHRs to physicians due to concerns that the items could be used to secure inappropriate referrals. However, the AMA advocated that a preferable approach is one focused more on the need for better education around the limits of the safe harbor and exception for EHR donations.

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Meaningful Use: Electronic Health Record (EHR) incentive programs

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Get more information on the incentives Medicare and Medicaid provide for medical practices to adopt new records, billing and practice management procedures.

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·      Data

·      Information

·      Knowledge

·      Wisdom

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Highlights

*

Nursing-specific and multi-disciplinary STs used by nurses across clinical settings.

*

STs facilitate interoperability, clinical decision making & improved documentation.

*

Benefits of STs depend on specific nurse, context, computer and education provided.

*

Few high quality studies and heterogeneity creates barriers to evidence synthesis.

Abstract

Aim

To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice.

Introduction

The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice.

Methods

A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG.

Results

One hundred and eighty three studies met the inclusion criteria. These were conducted across 25 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on the healthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs.

Conclusion

Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.

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Use of standardized terminologies in clinical practice: A scoping review

# data[].attributes.attachment_link.description
Nursing-specific and multi-disciplinary STs used by nurses across clinical settings. * STs facilitate interoperability, clinical decision making & improved documentation. * Benefits of STs depend on specific nurse, context, computer and education provided. * Few high quality studies and heterogeneity creates barriers to evidence synthesis.

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Why is the Use of Standardized Terminology Important for Nursing Practice?

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Why is the Use of Standardized Terminology Important for Nursing Practice?

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·      The use of standardized terminology allows documentation of clinical detail over time.

·      Structures data entry

·      Provides a shared understanding across care

·      Promotes collaboration of care

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Methods of Information in Medicine

An International Recommendation Framework of Core Competencies in Health Informatics for Nurses

Ursula Hübner, 1, Correspondence address Toria Shaw, ² Johannes Thye, ¹ Nicole Egbert, ¹ Heimar de Fatima Marin, ³ Polun Chang, ⁴ Siobhán O'Connor, ⁵ Karen Day, ⁶ Michelle Honey, ⁷ Rachelle Blake, ⁸ Evelyn Hovenga, ⁹ Diane Skiba, ¹⁰ and Marion J. Ball ¹¹

Summary

Background: While health informatics recommendations on competencies and education serve as highly desirable corridors for designing curricula and courses, they cannot show how the content should be situated in a specific and local context. Therefore, global and local perspectives need to be reconciled in a common framework.

Objectives: The primary aim of this study is therefore to empirically define and validate a framework of globally accepted core competency areas in health informatics and to enrich this framework with exemplar information derived from local educational settings.

Methods: To this end, (i) a survey was deployed and yielded insights from 43 nursing experts from 21 countries worldwide to measure the relevance of the core competency areas, (ii) a workshop at the International Nursing Informatics Conference (NI2016) held in June 2016 to provide information about the validation and clustering of these areas and (iii) exemplar case studies were compiled to match these findings with the practice. The survey was designed based on a comprehensive compilation of competencies from the international literature in medical and health informatics.

Results: The resulting recommendation framework consists of 24 core competency areas in health informatics defined for five major nursing roles. These areas were clustered in the domains "data, information, knowledge", "information exchange and information sharing", "ethical and legal issues", "systems life cycle management", "management" and "biostatistics and medical technology", all of which showed high reliability values. The core competency areas were ranked by relevance and validated by a different group of experts. Exemplar case studies from Brazil, Germany, New Zealand, Taiwan/China, United Kingdom (Scotland) and the United States of America expanded on the competencies described in the core competency areas.

Conclusions: This international recommendation framework for competencies in health informatics directed at nurses provides a grid of knowledge for teachers and learner alike that is instantiated with knowledge about informatics competencies, professional roles, priorities and practical, local experience. It also provides a methodology for developing frameworks for other professions/disciplines. Finally, this framework lays the foundation of cross-country learning in health informatics education for nurses and other health professionals.

Keywords: Health informatics competencies, nursing, inter-professional care, education, curriculum, workforce development, recommendations, methodology

1. Introduction

1.1 Health Informatics versus Nursing Informatics?

Identifying informatics competencies in nursing has had a long history and pertinent activities have increased over the last 15 years, with peaks between 2006 and 2009, staying at a high level afterwards [ 1 ]. This continued interest in education correlates with the advancement of information technologies, their implementation to support healthcare processes and the potential to make a difference in patient outcomes, and the health IT knowledge and skills gap in nursing [2 ]. Over the years, the focus on competency recommendations has shifted to reflect changing technical and other priorities in healthcare. For example, in 2001, educators distinguished between computer and informatics skills [3 ] and focused on technologies such as relational databases [4 ]. Although these recommendations have not become obsolete, the two examples highlight the need for continuously monitoring and updating informatics competencies in order to keep pace with on-going technical developments and their use.

As observed in other clinical informatics sub-specialties, informatics competencies in nursing belong to a cohesive field of its own known as "nursing informatics". However, the notion has grown that there has to be a common foundation with input from a variety of healthcare professions [ 5 ]. In this sense, the term "health informatics" comprises informatics for different disciplines and professions and recognizes inter-professionalism as an intrinsic feature of informatics [6 ]. This view matches activities to reshape healthcare from a silo dominated field to a process and patient oriented service, which requires health information technology (IT) to support inter-professional care across the continuum, based on proper process management and inclusive of quality management [7 , 8 ].

Informatics , which focuses on data, information, knowledge, the applications and the users themselves, is to be distinguished from Information Systems which focuses on the organizational use of health IT and from Information Technology , which primarily addresses systems development and system life cycle management issues [9 ]. Due to its focus on data, information and knowledge, health informatics needs to balance requirements that are specific to professions or roles and those that are generic and applicable across the spectrum of healthcare professionals. "What health informatics competencies are relevant for a special group of health professionals (e.g. nurses) and for different professional roles?" is thus a valid question and needs to be answered for each group separately.

1.2 The Benefit of International Recommendations in Education

As health IT industry is increasingly working in a global arena, international recommendations in medical and health informatics education [ 10 , 11 ] have become more desirable. Other trends also speak in favor of a global perspective. While traditional education is always situated in a local context, new modes of teaching and learning for example, such as Massive Open Online Courses (MOOCs) [12 ], are emerging that fulfill a niche for hundreds of thousands of learners from diverging backgrounds, different settings and countries. Recommendations taking a global perspective therefore match the idea of MOOCs. Research and education form a strong alliance at all levels of the translational process to improve health practice. Research, which is defined by internationally valid standards, strongly depends on the collection, analysis and publication of electronic data, also from nursing [13 ] and from sites in different countries [14 ]. Thus, informatics competencies play an essential role in the education of health and nursing researchers in order to work successfully in an international environment.

Furthermore, international recommendations can foster harmonization of education and may increase workforce mobility across countries [ 15 ]. In this light, the European Union (EU) and the United States of America (USA), signed a Memorandum of Understanding (MoU) focused on health IT in 2010. The MoU agreed to further develop the workforce's health IT skills to fully utilize the potential of new and emerging technologies. This work took place from 2013-2015 under the direction of the EU-US Workforce Development Workgroup (WDW), which compiled the results of an analysis that mapped competencies in the form of the HITCOMP (Health IT COMPetencies) Tool and Repository [15 , 16 ].

1.3 Learning and Teaching: the Competency Based Approach

Competency based approaches have increasingly gained attention in the context of medical and nursing education over the last decades [ 17 , 18 , 19 ] to overcome the shortcomings of the pure topic related approach. In psychology, competencies are understood as "[...] a roughly specialized system of abilities, proficiencies, or skills that are necessary to reach a specific goal." [20 ]. Competencies as such embrace a set of behaviors and intent and cover cognitive, social and emotional aspects of performance [21 ]. Due to the close relationship between "demands, tasks, problems, and goals" [20 ] and respective competencies, competency based learning is always associated with a specific role, scenario or task domain. For example, there are specific competencies for the nurse leader role [22 ] or for inter-professional cooperation [23 ]. In this context, we will refer primarily to cognitive competencies, which encompass the acquisition and understanding of new knowledge through iterative mental processes of sensing, experiencing, thinking and reasoning/interpreting [21 ]. We will focus particularly on those cognitive competencies that contribute to the successful accomplishment of nursing roles within an organization. In accordance with management theory [24 ], which refers to entire organizations, we call them "core competencies" of the professional role.

There are various frameworks that breakdown and describe competencies. According to some frameworks, competencies consist of both knowledge and skills [e.g. 25, 26]. These frameworks either refer to different (academic) levels [ 10 , 27 ] or at a specific level, e.g. graduate programs [25 , 28 ]. Competencies can be graded along Bloom's modified six cognitive process dimension terms (i.e. remember, understand, apply, analyze, evaluate and created) referring to "factual knowledge", "conceptual knowledge", "procedural knowledge" and "metacognitive knowledge" [29 ] or as "prerequisite knowledge and skills", "fundamental knowledge" and "procedural knowledge and skills" [25 ].

Although health informatics knowledge is global and requires international recommendations, education is typically local and the competencies addressed in the study programs and courses have to be embedded into the environment where they will be used. These two controversial requirements have to be reconciled in order to assist teachers and learners effectively in their efforts. The primary aim of this study is to empirically define and validate a framework of globally accepted core competencies in informatics and to enrich this framework with exemplar information derived from local educational settings. The methodology for developing a framework of this type should be applicable for any kind of target group. Within this study, the framework was developed for nurses with a focus on the professional roles they typically hold. The study was performed within the TIGER ( Technology Informatics Guiding Education Reform ) Initiative that includes an international network of nursing experts and reaches out to the entire community of healthcare professionals.

2. Methods

2.1 The TIGER Approach

In response to the initial formation of the Office of the National Coordinator for Health Information Technology (ONC) in the United States of America in 2004, the TIGER Initiative was officially launched in 2006 when key nursing stakeholders convened to ensure nursing was included in the mandate for health informatics education and application.

TIGER is dedicated to enabling clinicians, particularly nurses, to better exploit the use of informatics tools, their principles and underlying theories to improve patient care [ 30 ]. In 2012, the TIGER International Committee was established to widen the reach of TIGER activities in the international scientific community. When TIGER transitioned from a standalone initiative to the Healthcare Information and Management Systems Society (HIMSS) in 2014, the scope was extended to include other clinical disciplines and to enter into an inter-professional space even beyond clinicians. Today, TIGER seeks to empower educators as change agents and learners to prepare the inter-professional, inter-disciplinary clinical workforce for the digital age [31 ]. Based on these goals, TIGER initiated the international informatics competency synthesis project, which seeks defining and validating a recommendation framework.

2.2 Overview of Methodological Steps

In order to achieve this aim, a mixed method approach was pursued that combined quantitative and qualitative methods and iteratively validated the core competency areas while enriching the framework.

Figure 1 provides an overview of the three steps used to launch and finalize this project inclusive of the methods applied and the perspective from which the information was captured.

2.3 Survey

In order to identify globally relevant core competency areas to be represented in the framework, a survey was conducted. This survey made use of an existing online questionnaire [ 32 ] that had been designed drawing upon international literature, that had been further refined in two workshops and tested in three countries [32 ]. The questionnaire was comprised of 24 core competencies areas in health informatics, which had been extracted from the international literature [10 , 11 , 18 , 25 , 33 , 34 , 35 ] and embraced 10 technological items (e.g. eHealth, telematics and telehealth), two legal and ethical items (e.g. data protection, ethics and IT), 11 IT related management items (e.g. project management, change management) and finally, biostatistics/statistics. Five professional roles of nurses were targeted in accordance with the methodology established prior to this study [32 ]: 1) clinical nursing (e.g. care planning), 2) quality management (e.g. organizational development), 3) coordination of inter-professional care (e.g. case management), 4) nursing management (e.g. ward or hospital management) and 5) IT management in nursing (e.g. introduction of new IT systems). A role-based approach was chosen because role specific training for different groups of health professionals had been identified as a highly desirable action in order to increase the health IT skills of the healthcare workforce [36 ]. The meaning of these roles was explained by examples (see ►Online Appendix A). Survey participants were asked to rate the relevance of the 24 core competency areas within the five roles on a scale from 0 to 100. In order to help survey participants to get a more detailed understanding of what these core competency areas meant, examples subsumed under these core competency listings were given (►Online Appendix A). We did not distinguish between the different cognitive process dimensions "factual knowledge", "conceptual knowledge", "procedural knowledge" and "metacognitive knowledge" or any other gradating categories because this specification would have required assumptions on the (academic) level of the learning and teaching activities. It is important to note that these level differences were out of the scope of this survey. The core competency areas were presented in alphabetical order.

A personalized link to the questionnaire was sent to 72 people from 24 countries in the Americas (6 countries), Europe (10 countries), Asia (6 countries), and Australia/Pacific (2 countries). Participants were either a member of or associated with the International TIGER Committee. As TIGER comprises primarily experts with an interest in education, the majority (46%) came from universities, 26% came from health IT industry, 14% from hospitals (including university hospitals), 13% from professional associations and 1% did not give any information about their affiliation. All survey participants are regarded as high profile experts in their countries. The survey was open from November 23, 2015 to January 18, 2016. Out of the 72 experts invited, we yielded 43 responders (response rate approximately 60%). They came from 21 countries: Americas (4 countries), Europe (10 countries), Asia (5 countries) and Australia/Pacific (2 countries) and had the following affiliation: 37% from universities, 21% from health IT industry, 35% from hospitals (including university hospitals) and 7% from professional associations.

2.4 Workshop

In order to validate the survey findings within a global expert community, a workshop was held at the 13 th International Congress on Nursing Informatics (NI2016) in Geneva on June 28, 2016 [37 ]. The aim was to find out if core competency areas were missing and how to cluster them. Twenty-eight experts from 13 countries on four continents attended the workshop (six of the experts had participated in the survey). Workshop attendees reported the following types of affiliation: 39% universities, 25% hospitals (including university hospitals), 18% health IT industry, 11% professional associations and 7% gave no information. Following an introduction to the aims and visions of the TIGER Initiative, the results of the international survey on core informatics competency areas were presented and made available to the audience as a handout. The workshop then focused on discussing informatics competency issues with workshop attendees. The discussion was stimulated with the following questions: (1) "What are the top 5 informatics competencies for nurses according to your experience?" and (2) "What is your opinion about the core competency areas just presented?". The discussion was recorded and all contributions were summarized utilizing the inductive categorization method. This work included five persons from the team of authors (UH, TS, MB, HM, PC) who additionally clustered the individual competencies making use of the greater domains also mentioned by the experts at the workshop. These domains were mapped to the 24 core competency areas by the same team members plus one other author (OS). Cronbach's alpha was computed to test the internal consistency of these domains across the five nursing roles. An alpha value of 0.70 and above was interpreted as "satisfactory" in accordance with the literature [38 ].

2.5 Case Studies

Local exemplar case studies, which were compiled for this study, should illustrate the use of the core competency areas selected to represent leading institutions of education in the field of nursing and health informatics. One case study per country was chosen covering Brazil (BR), Germany (GER), New Zealand (NZ), Taiwan/China (TW-CHN), the United Kingdom (UK) and the United States of America (USA). These countries were selected to mirror a variety of different (professional) cultures. While conducting this study, no case study from an African country was available to be included into this project. These case studies should provide background information on educational institutions, varying types of students, the academic level, teaching strategy and the educational format. They also should describe if and in which way informatics core competency areas were addressed by these courses and programs. Thus, they were meant to serve as exemplars of teaching and learning individual competencies included in the core competency areas and potentially beyond.

2.6 Ethical Considerations

The methodology of this study was presented to the Ethical Committee for Research at Hochschule Osnabrück Germany, which decided that there was not need to submit a full proposal to the Committee.

3. Results

3.1 Overview

The three-step methodology resulted in a recommendation framework that consists of globally accepted core competency areas:

1. sorted by relevance within five different professional roles in nursing based on the empirical findings of the survey,

2. clustered by coherent overarching domains identified in the workshop and verified by a reliability analysis and

3. illustrated and validated by educational programs and courses in various countries by case studies.

The framework provides recommendations for high priority core competency areas to be addressed when developing curricula for the five professional roles in nursing. It also gives advice regarding the cohesion of core competency areas. Finally, it allows insight into how these areas are broken down into individual competencies in different local settings and for different purposes. This approach resulted in very concrete recommendations but also demonstrates the feasibility of the methodological approach. Each study step is described in-depth in the following sections.

3.2 Global Relevance of Core Competency Areas for Professional Roles in Nursing

► Table 1 shows the priority list and outlines the core competencies areas per professional role. Each role was characterized by one to three lead core competency areas with (nearly) the same mean percentage of relevance (in italics ► Table 1 ) and by a specific profile of core competency areas. In this sense, the leading core competency area for clinical nursing and nursing management was nursing documentation . For the quality management role, it was quality management and for coordination of inter-professional care, it was data protection and security and information management and knowledge management in patient care . For IT management in nursing, there were three (nearly) equally important core competency areas: information systems and communication systems , principles of nursing informatics and data protection and security . There was a mixture of genuine IT competency areas (e.g. information systems and communication systems), IT related management areas (e.g. strategic management and leadership), and legal and ethical issues. Competencies in the areas of nursing documentation and information management and knowledge management in patient care could be found among the top 10 in all five roles. The same held true for competencies in the area of principles of nursing informatics . Data protection and security , process management as well as quality management were rated as highly relevant in four out of the five roles among the top 10 areas of competencies.

Table 1

Clinical Nursing (Direct Patient Care)

Core competency area

REL ± SD, n = 41

Quality Management

Coordination of Inter-professional Care

Nursing Management

IT Management in Nursing

Other core competency areas were rather distinctive, such as strategic management and leadership , which appeared among the top 10 only in nursing management, and assistive technology for ageing people , which belonged to the top 10 only in clinical nursing.

Besides these more role specific considerations, the survey results also revealed the importance and relevance of many health informatics core competency areas. Mean relevance values of core competency areas ranking at position 10 still ranged between 69.0 and 83.4 across all roles ( Table 1 ).

►Online Appendix B provides an overview of the ratings for all 24 core competency areas within the five roles.

3.3 Validation and Clustering of the Core Competency Areas

When asked about the highest priority of core competencies, workshop attendees mentioned a variety of different items and competencies including greater core competency areas. These different statements were analyzed with the aim of identifying similarities and differences with regard to the 24 core competency areas (validation) and with the aim of clustering these areas. Based on the consensus of five experts from the team of authors, four domains emerged from these statements. ► Table 2 (left column) shows the domains, the corresponding items and competencies resulting from summarizing the workshop findings and finally the associated core competency areas from the survey (right column). All statements could be matched with core competency areas.

Table 2

Domains of competency areas

Associated core competency areas (main similarities)

Data, information and knowledge (DIK) domain

1) know how to use data/information not only how to enter data

2) perform care planning and use of data

3) make use of indicators (information) for decision making

4) analyze what data are needed and are useful, link to data/information science

7) information governance

Information exchange and information sharing (IEIS) domain

1) continuity of care

2) sharing of information with the patient, work in partnership, learn to listen

4) health information exchange

Ethics and legal issues (EL) domain

1) ethics

Systems life cycle management (SLCM) domain

1) address requirements

3) design thinking

The four domains derived from the expert statements were used as an initial structure to cluster the 24 core competency areas. As there were some areas that could not be assigned to one of the four domains, two more clusters were introduced by the five experts from the team of authors, which then resulted in six final domains. Two core competency areas were assigned to two domains, i.e. assistive technology for ageing people and information and communication systems. Table 3 shows the clustering and the internal consistency values of these domains computed by Cronbach's alpha.

Table 3

Domains

Clinical nursing (n = 41)

Quality management (n = 41)

Coordination of inter-professional care (n = 41)

Nursing management (n = 43)

IT management in nursing (n = 41)

Principles of nursing informatics

Information and knowledge management in patient care

Nursing documentation (including terminologies)

Information management in research

Information management in teaching, training and education

Resource planning and logistics

Information and communication systems

Applied computer science/informatics

Strategic management and leadership

Change management and stakeholder management

Human resource management

All Cronbach's alpha values were 0.70 or larger ("satisfactory") [ 37 ] with the only exception of ethics and legal issues (EL) for nursing management, which reached a value of 0.67. In summary, the expert statements from the workshop attendees could be mapped to the 24 core competency areas of the survey (► Table 2 ) and provided a consistent structure for clustering the core competency areas (► Table 3 ).

3.4 Illustration of Core Competency Areas by Cases Studies and the Final Recommendation Framework

The selected exemplar case studies covered educational activities for nurses in six countries, including two case studies describing courses at the undergraduate level (BR, UK-SCO), two at the postgraduate level (NZ, USA) and two at the certificate level in continuing education (GER, TW-CHN). There were exemplar case studies that embraced single courses (BR, GER, NZ, TW-CHN, USA) and one that described a sequence of learning units embedded in a nursing program (UK-SCO). Similarly, four of the case studies focused on nurses (BR, GER, TW-CHN, UK-SCO), one primarily on nurses but also on informatics students (USA) and the other was entirely inter-professional (NZ). In all six cases, the courses were or are designed drawing on national recommendations [e.g. 32, 39, 40, 41] or developments (BR, GER, NZ, TW-CHN, UK-SCO, USA. The case studies are described in full length in ►Online Appendix C. Competencies tied to the core competency area in each exemplar case study are represented as building blocks. These building blocks contain competency descriptions in each area (► Figure 2 ).

Table 4 constitutes the recommendation framework consisting of the core competency areas, their mean relevance values, the associated domains and the case study building blocks referring to the core competency areas. It hereby shows the distribution of competency building blocks from individual exemplar case studies. It mirrors the breadth and depth of the courses described and the competencies associated.

Table 4

Roles

Clinical nursing (direct patient care)

Quality management

Coordination of inter-professional care

Nursing management

IT management in nursing

Core competency area

Domains

REL n = 41

Covered by case studies from

REL n = 41

Covered by case studies from

REL n = 41

Covered by case studies from

REL n = 43

Covered by case studies from

REL n = 41

Covered by case studies from

Information and knowledge management in patient care

DIK

82.2

83.2

85.4

84.0

86.1

Decision support by IT

DIK

70.2

72.7

70.0

74.7

85.4

Information management in research

DIK

51.0

72.4

60.5

63.3

71.5

Information management in teaching, training and education

DIK

61.7

67.1

66.1

70.0

74.4

Resource planning and logistics

DIK

56.6

65.4

71.7

76.0

71.7

eHealth. telematics and telehealth

IEIS

69.5

69.8

77.6

66.3

80.0

The case studies from Brazil and UK-Scotland were similar with regard to addressing undergraduate students in their role as clinical nurses, i.e. direct patient care. As these were beginner courses, they focused primarily on the informatics essentials of healthcare professionals. They differed with regard to the number of teaching hours. The Brazilian course, which was a single course, included 30 hours, whereas the Scottish course covers a set of learning units that is integrated into pre-registration nurse training. These competencies matched with the ones for clinical nursing in the top 10 priority list ( Table 1 ) closely.

The US course addressed core competency areas for graduate nurses working in different roles. As a self-paced online course, no specific information on its duration was given. It emphasized competencies associated with the selection, use and evaluation of different types of systems and the exploitation of data, information and knowledge for patient care and research. The New Zealand course covered a large range of informatics competencies for various roles, which corresponded with its design as an inter-professional series of four or eight courses towards a certificate or diploma in health informatics respectively (with 150 teaching and learning hours per course). The German continuing education course was highly specialized in nursing management and analytics while being restricted in its duration (30 hours). It embraced all core competency areas of the top 10 priority list (► Table 1 ) for the role of nursing management and included statistics. It also assumed that certain competencies were already available. The Taiwan-China course was an example how developments in one country (Taiwan) were transferred to another country (China). It spanned a large range of core competency areas that were manifested in a 7-day hands-on workshop focused on learning advanced spreadsheet management and programming.

These exemplar case studies also revealed areas only partly covered by the 24 core competency areas. The case study from the USA emphasized competencies that aim to enable health professionals to teach patient/citizen digital health literacy. This approach is closely associated with consumer health informatics. Furthermore, the Scottish case study considered health service literacy, which encompasses knowledge about the national healthcare system, its professionals, roles and processes, as informatics is embedded within this wider context which is critical to understand.

4. Discussion

4.1 Recommendation Framework

We propose a framework consisting of 24 core competency areas in health informatics and five major roles of nurses. The core competency areas were ranked by international experts in a survey, validated by a different group of experts in an international workshop and clustered into six domains. Four domains are equivalent to the domains derived from the workshop expert discussion, i.e. data, information, knowledge; ethical and legal issues; information exchange and information sharing and system life cycle management. The fifth domain summarizes the core competency area that focuses on management activities in the context of informatics. Finally, the sixth domain subsumes biomedical imaging, assistive technology for ageing people and signal processing and biostatistics/statistics . Nearly all domains have at least "satisfactory" or better values for internal consistency across all roles and can be therefore regarded as reliable. The constituents of these domains, the core competency areas, had been extracted from a comprehensive analysis of the international literature and had been validated in two workshops [32 ] prior to this study. In this study, the core competency areas were again validated in a workshop and also via the cases studies. From this multi-layered process, it can be concluded that these areas are valid.

The cells of the matrix framework contain the relevance ratings of international experts. From a global perspective, we recommend areas of core competencies with high relevance ratings in their respective role ( Table 1 ), the globally accepted core competency areas in health informatics for nurses. The interpretation of what is a "high" or a "low" relevance is not given by this framework intentionally to leave the meaning of these values open to the user. The resulting globally accepted areas are meant to function as a compass to show the direction towards areas of high relevance and/or towards domains of high internal consistency. They should help learners and teachers find their route through the large realm of information technology and its application in healthcare. These recommendations are complementary to the TIGER recommendations [35 ] focused on basic IT skills.

From a specific perspective, we recommend learning from the examples provided within the different exemplar case studies. They are detailed enough with regard to (academic) levels, cognitive process dimensions and competencies at the layer of cognitive activities [ 29 ]. They are also situated in a specific context defined by the national healthcare system, the educational system of nurses and other clinicians, status of health IT adoption and culture. The case studies, which refer to the core competency areas, demonstrate how these competencies are combined to form an entire curriculum or program. We recommend that readers construct their personalized set of objectives for learning and teaching from the core competency areas and case studies. The framework is instantiated by the case studies, which indicate the core competencies that are primarily addressed.

The exemplar case studies illustrate the need for diversity in learning and teaching. This may lead to the inclusion of some competencies outside the globally accepted informatics core competency areas, e.g. statistics in the German case study. Due to the fact that the globally accepted areas consist of many core competencies, which cannot be considered in one single course, a selection has to be made that reflects local or cultural differences. Also, the teaching and learning styles may differ. The Taiwan-Chinese course allows the nurses to dive deeply into technology; the USA course incorporates a clinical case, which acts as a red thread to exemplify the use of informatics; the Scottish program accompanies the baccalaureate nursing program in the sense of a spiral learning approach; the New Zealand course pursues a fully fledged inter-professional approach; and finally, the Brazilian course is strongly tied to the establishment of nursing education as such.

The mixed methods approach combined a survey with case studies to warrant the integration of different perspectives to build the recommendation framework.

4.2 Limitations and Strengths

We did not include the roles of nursing teachers and scientists because both roles are very much dominated by the roles they refer to when teaching nurses and clinicians and when conducting research. Thus, a nursing teacher working with students in quality management should dispose of similar competencies as quality managers themselves. Likewise, nursing scientists conducting research in clinical nursing should be familiar with competencies of nurses working at the point of care. Furthermore, information management in research is a core competency area of its own that directly addresses the needs of researchers. The role-based approach as such was neither questioned in the survey nor at the workshop. Clinical nursing [ 14 , 42 , 43 ], quality management [44 ], care coordination [45 ], nursing management, i.e. leadership [46 ] and IT management in nursing as informatics nurse specialist [47 ] or as chief nursing information officer [48 ] are roles with a high informatics affinity that are well accepted by the current literature and are generic enough to cover inpatient and outpatient settings. There are certainly more roles nurses can take on, which are not explicitly considered in this framework, for which the framework, however, could offer a rough orientation.

Although we regard communication as a highly desirable competence, particularly in the context of change management and inter-professional care, we argue that communication aligns better with social and horizontal competencies and is therefore out of the scope of the framework at this stage. Moreover, it also appears as a sub-competence in many core competency areas, particularly those that focus on innovation and change.

Our findings are corroborated by other studies. Competencies of nurse leaders [ 21 ] match - despite a different clustering - to a large extent with the core competency areas for nursing managers within our study. The same applies to other global compilations of competencies in nursing informatics [49 ] and clinical informatics [50 ].

This study does not provide a picture of competencies that distinguish health informatics in nursing from health informatics for other healthcare professionals because this study did not compile information about these other healthcare professions. Due to the role based approach it could be hypothesized that roles better define the need for a certain competency pattern than professions, e.g. the role "coordination of inter-professional care". However, a profession is constituted by its body of knowledge and methods thus the details within the domain "data, information and knowledge" should vary to some extent for different professions despite a potential similarity at the formal level.

It is very likely that new competency areas will emerge as the framework is constantly instantiated with more exemplar case studies (inclusive of African countries) and is used in real life. When the framework needs updating, formalized methodologies for the following tasks can assist with this process: a) identifying and updating core competency areas, b) measuring their relevance throughout the international community and c) adding international exemplar case studies that illustrate these core competency areas and provide insight into the competencies and local curricula.

4.3 Outlook

The procedure of conducting a survey, obtaining feedback in a workshop and including exemplar case studies provided knowledge about the validity of core competency areas and about new competencies to be included. In particular, we propose adding consumer health informatics as a core competency area due to the high importance of patient-centered healthcare and the requirement that healthcare professionals share data, information and knowledge with patients and citizens [51 ]. This addition would bundle competencies that are already included in the framework such as referred to by "telehealth" and "assistive technologies for ageing people" and would highlight this area. As not all core competency areas are yet covered by case studies, there is a need to integrate additional ones in the future.

5. Conclusions

This international recommendation framework for core competency areas in health informatics for nurses aims at providing a grid to embrace knowledge about competencies, professional roles, priorities and practical experience. The framework refers to the term health informatics in nursing to demonstrate its rooting in nursing informatics [45 , 52 ] and its openness towards other healthcare professionals and their interaction with nurses. We contend that learning and teaching on the individual level are active processes of constructing the educational space. Therefore, our recommendations should work as a framework that guides and stimulates learners and teachers alike. It should leave enough room for individual creativity, aspiration for innovation and personal fulfillment. Due to technology being a moving target, this recommendation framework should be revised and updated regularly. We propose a five-year period of validity.

Acknowledgment

We wish to thank all international experts who contributed to the survey and the workshop. We also thank Beth Elias, PhD, Term Associate Professor at Virginia Commonwealth University, Richmond, VA, USA, for her assistance in preparing this manuscript.

A preliminary version of this paper was presented at the multi-conference HEC2016 in August 2016 in Munich/Germany.

Funding Statement

Funding : This work was supported by the European Commission within Horizon 2020 grant number (Grant Agreement 727552 EUUSEHEALTHWORK), HIMSS North America, the HIMSS Foundation and the Federal Ministry of Education and Research (bmbf) Germany grant number (16OH21026).

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Technology Informatics Guiding Education Reform - TIGER : An International Recommendation Framework of Core Competencies in Health Informatics for Nurses

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