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-It is very important that as healthcare workers we familiarize our selves with current legal and ethical issues
-In doing so we can prevent ongoing medical errors from occurring or better yet leading to patient injury/death
-As providers, it is not always clear what is best for the patient and of times it is a combination of many things

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Quick read on some of the ethical issues concerning healthcare today which include:
1. DNR
2. Doctor and patient confidentiality
3. Malpractice and negligence
4. Access to care
5. Physician Assisted Suicide

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Data Visualization Benefits and breakdown

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Data Visualization Benefits and breakdown

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Understand the Importance of Data Visualization in Healthcare

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Research reveals that big data in the healthcare market is going to increase by $34.27 billion by 2022.

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-Data visualization can be vey helpful to help improve patient engagement
-For example, when providing teaching with a family in regards to a newly diagnoses of sickle cell disease, I have found that families do better when there is visuals involved
-Especially pictures of what red blood cells look like in the body and how they are able to transport oxygen throughout the body
-Parents get to see the difference between a normal hemoglobin vs a sickled one
- The visual allows them to understand the importance of hydration as well as medication adherence
-Other helpful data visuals include welcome videos each caregiver has to watch before being able to use the TV
- It explains the different roles the care team has, ect.

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-This week I has highly moved by the TED talk. In particularly the importance of story telling. The speaker focused on four key things when it comes to story telling including:
-Connecting with people
-conveying one idea
-keeping it simple
-exploring the things you know best
- I believe that in a world where technology has allowed to connect with people around the world, it seems as though we are less connected with each other. Thus, I believe connecting with people is very important. Conveying an idea and keeping it simple also major. Things that are to complex to explain can cause the speaker to get off topic and or lose the audience. Rather it would make sense why sticking to one topic and keeping it simple will very likely continue to keep the audience engaged. Finally, exploring this you best know will help you build credibility among your audience.

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-Technology has allowed us to make good strives, however there are still concerns about privacy and security
-As a provider it is important that I keep up with the latest company policies
-Educating staff on the importance of maintaining patient confidentiality is also a must

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I was shocked to read that it was only

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule.

HIPAA Privacy Rule

The Privacy Rule standards address the use and disclosure of individuals' health information (known as protected health information or PHI) by entities subject to the Privacy Rule. These individuals and organizations are called "covered entities."

The Privacy Rule also contains standards for individuals' rights to understand and control how their health information is used. A major goal of the Privacy Rule is to make sure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high-quality healthcare, and to protect the public's health and well-being. The Privacy Rule permits important uses of information while protecting the privacy of people who seek care and healing.

Covered Entities

The following types of individuals and organizations are subject to the Privacy Rule and considered covered entities:

Healthcare providers: Every healthcare provider, regardless of size of practice, who electronically transmits health information in connection with certain transactions. These transactions include:

Claims

Benefit eligibility inquiries

Referral authorization requests

Other transactions for which HHS has established standards under the HIPAA Transactions Rule.

Health, dental, vision, and prescription drug insurers

Health maintenance organizations (HMOs)

Medicare, Medicaid, Medicare+Choice, and Medicare supplement insurers

Long-term care insurers (excluding nursing home fixed-indemnity policies)

Employer-sponsored group health plans

Government- and church-sponsored health plans

Multi-employer health plans

Exception: A group health plan with fewer than 50 participants that is administered solely by the employer that established and maintains the plan is not a covered entity.

Healthcare clearinghouses: Entities that process nonstandard information they receive from another entity into a standard (i.e., standard format or data content), or vice versa. In most instances, healthcare clearinghouses will receive individually identifiable health information only when they are providing these processing services to a health plan or healthcare provider as a business associate.

Business associates: A person or organization (other than a member of a covered entity's workforce) using or disclosing individually identifiable health information to perform or provide functions, activities, or services for a covered entity.These functions, activities, or services include:

Permitted Uses and Disclosures

The law permits, but does not require, a covered entity to use and disclose PHI, without an individual's authorization, for the following purposes or situations:

Disclosure to the individual (if the information is required for access or accounting of disclosures, the entity MUST disclose to the individual)

Treatment, payment, and healthcare operations

Opportunity to agree or object to the disclosure of PHI
An entity can obtain informal permission by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object

Incident to an otherwise permitted use and disclosure

Limited dataset for research, public health, or healthcare operations

Public interest and benefit activities-The Privacy Rule permits use and disclosure of PHI, without an individual's authorization or permission, for 12 national priority purposes:

1. When required by law

2. Public health activities

3. Victims of abuse or neglect or domestic violence

4. Health oversight activities

5. Judicial and administrative proceedings

6. Law enforcement

7. Functions (such as identification) concerning deceased persons

8. Cadaveric organ, eye, or tissue donation

9. Research, under certain conditions

10. To prevent or lessen a serious threat to health or safety

11. Essential government functions

12. Workers' compensation

HIPAA Security Rule

While the HIPAA Privacy Rule safeguards PHI, the Security Rule protects a subset of information covered by the Privacy Rule. This subset is all individually identifiable health information a covered entity creates, receives, maintains, or transmits in electronic form. This information is called electronic protected health information, or e-PHI. The Security Rule does not apply to PHI transmitted orally or in writing.

To comply with the HIPAA Security Rule, all covered entities must:

Ensure the confidentiality, integrity, and availability of all e-PHI

Detect and safeguard against anticipated threats to the security of the information

Protect against anticipated impermissible uses or disclosures that are not allowed by the rule

Certify compliance by their workforce

Covered entities should rely on professional ethics and best judgment when considering requests for these permissive uses and disclosures. The HHS Office for Civil Rights enforces HIPAA rules, and all complaints should be reported to that office. HIPAA violations may result in civil monetary or criminal penalties.

For more information, visit HHS's HIPAA website.

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Health Insurance Portability and Accountability Act of 1996 (HIPAA) | CDC

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HIPAA is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed.

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This blog provides a quick read to the difference between patient portals and personal health records as well well as the benefits

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What is the difference between Patient Portals and Personal Health Records (PHRs)? Traditionally, a Patient Portal is an extension of an EHR, EMR, or Hospital system. Data from one of these systems is published to the portal. The patient is provided with a secure login and can view results or clinical information and interact with healthcare providers by submitting messages, booking appointments, or requesting medication renewals. The Portal is controlled by the source system (EMR/EHR/Hospital). On the other hand, the Personal Health Record (PHR) is more patient centric, is controlled by a patient or family member, and may or may not be connected to a doctor or hospital (i.e. it may be tethered or untethered). Information in the PHR is shared at the discretion of the patient.

The above description is quite simplistic and based upon the manner in which these tools have generally been developed; however, PHRs and Patient Portals are now beginning to merge both capabilities into a single product. For example, an EHR vendor or hospital system may offer a patient portal that is accessed through a browser as well as a PHR that is under the control of the patient. The key differentiation is control. In the PHR, a patient controls who has access to their data vs. the EMR and EHR, in which the provider or health organization controls the information.

A study designed to examine patient loyalty as measured by retention in a health plan was conducted between 2005 and 2008 with 394,000 Kaiser Permanente Northwest members. Study authors estimated retention rates between My Health Manager users (the Kaiser Permanente PHR) and non-users. In this study, the use of a Personal Health Record linked to the Kaiser Permanente Electronic Health Record, was a significant predictor of patient loyalty. Users of the PHR were 2.578 times more likely to choose to remain members than were non-users. (Am J Manag Care. 2012;18(7):e248-e253)

In a time-pressured healthcare system, are there better mechanisms to share this information? Phone calls, although personal, have logistical challenges due to the availability of either the physician or office staff to provide the services, as well as the need to leave voice messages when patients are not available to take a call.
Benefits of Personal Health Records include:

Continuity of records - people move, change jobs, and change doctors.

Patients becoming more engaged in managing their own healthcare is associated with better outcomes.

Passing control for certain tasks over to patients can reduce telephone calls and other administrative workloads in practices, e.g. view own lab results and reports.

One caution: information in a PHR can be more accurate, reliable, and up to date; however, it requires effort from patients and their care providers.

Benefits of Patient Portals include:

Ability to view lab and diagnostic imaging results through secure login.

Appointment scheduling and prescription renewal requests.

Ability to communicate with healthcare providers.

Reminders and notifications for appointments, results, and upcoming diagnostic investigations.

Downloadable registration forms or pre-clinic assessment forms.

Consumer health information on relevant diseases or clinical conditions.

Under the Stage 2 Meaningful Use requirements (which will begin as early as 2014), >5% of patients must send secure messages to their physician and >5% of patients must access their health inforomation online. Offering a patient portal will allow practices to meet these requirements.

Have you had experience with PHRs or Patient Portals? What are the benefits and challenges? Share your thoughts or comments.

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Patient Portals and Personal Health Records

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What is the difference between Patient Portals and Personal Health Records (PHRs)? Traditionally, a Patient Portal is an extension of an EHR, EMR, or Hospital system. Data from one of these systems is published to the portal.

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Interesting read on the relationship between gamification and healthcare

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Changing Behaviors with the Gamification of Healthcare

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Gamification intersects with two significant assets in healthcare - people and technology - and offers a way to transform employee and consumer engagement.

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This article looks into the benefits of gamification; the positive effect that usability has on developing and using gamified systems

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Informative article looking into the future of TeleHealth. It further discussess how Telehealth has and will continue to grow in popularity given the increase needs of patients living with chronic diseases. The BiPartism Budget Act of 2018, will allow providers to respond to the needs of patients who once were not covered given their geographic area. Past regulations and healthcare legislation mad it difficult for providers to utilize Telehealth, however more states have come together to adopt Telehealth and therefore increasing rates allowing it to grow exponentially.

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How Telehealth Will Address Future Healthcare Needs

Telehealth continues to grow at an accelerated rate around the world. The market is expected to grow at a CAGR of 14.9% over the forecast period 2019 to 2026 as more hospitals and healthcare facilities bring this technology online. Telehealth has the potential to reduce healthcare costs, improve patient outreach and health outcomes, and change the way providers treat their patients.

As time goes on, telehealth technology will only get more advanced, further accelerating its influence in the healthcare industry. New devices and programs are helping providers better their patients and respond to ongoing health crises, such as the coronavirus.

Several states and countries are set to vote on meaningful telehealth legislation in the coming months. Discover the future of telehealth as we look ahead to 2020 and beyond.
Rising Demand for Telehealth Services
Telehealth continues to grow in popularity here in the U.S. and abroad largely due to the fact that more individuals are suffering from chronic diseases than ever before. According to the U.S. National Center for Health Statistics, there are currently around 40 million Americans limited in their usual activities due to one or more chronic health conditions. Furthermore, chronic diseases affect approximately 133 million Americans, representing more than 40% of the total population of this country. By 2020, that number is projected to grow to an estimated 157 million, with 81 million having multiple conditions.

When individuals are limited in their daily activities, they may have trouble visiting the doctor in person. Care providers can better monitor these patients as their condition continues to change, while keeping them at home where they feel more comfortable. As the number of patients with chronic diseases increases, so does demand for providers. Healthcare professionals can use telehealth to better manage their patients, reduce no-shows and last-minute cancelations, improve efficiency, and reduce costs.

The rising number of patients with chronic conditions is largely due to the aging population. Elderly patients continue to account for the lion's share of healthcare costs in the U.S. Care providers are using telehealth to better treat and manage these patients, many of which may have trouble visiting their care
provider in person.
The Latest in Telehealth Legislation
2020 is on track to be a major year for telehealth expansion. Thanks to the Bipartisan Budget Act of 2018, all Medicare two-sided ACOs will now be reimbursed for telehealth delivered services to the home. They will also be exempt from Medicare's geographic requirement, which will help providers better respond to the needs of elderly patients. Seniors no longer have to be in a specific geographic location, such as a Health Professional Shortage Area (HPSA), to access telehealth services. We should see more providers, particularly those caring for elderly patients, utilizing this technology in the years to come now that Medicaid has loosened these restrictions.

Several states, including California and Georgia, have recently updated their laws to improve access to telehealth services. Many of these laws establish payment parity for telehealth services, which means providers will be reimbursed at the same rate as they would for services rendered in person. More states are also making room for remote patient monitoring and store-and-forward services, which will help providers monitor and care for patients that may be too sick to visit the office in person, such as those recovering from surgery, elderly patients, and those with chronic conditions.

Uneven regulation and healthcare legislation have made it difficult for providers to adopt this technology in years past, but as more states unify their efforts to increase adoption rates, telehealth will likely continue to grow at an exponential rate.

The U.S. continues to be the leading market for telehealth services, but several other countries and continents are making room for this technology, as well. Europe is on track to become the second-largest market for telehealth, while the Asia-Pacific region is the fastest-growing region in the global market due to the rise in the geriatric population.

Telehealth will continue to grow at a rapid rate here in the U.S. and around the world. Companies large and small are looking for ways to reduce healthcare costs while better serving the elderly population and those suffering from chronic conditions. Providers will need to adjust their approach to medicine and healthcare as these trends continue to take shape. Telehealth can help providers better meet the needs of their patients without sacrificing the overall quality of care.

Visit InTouch Health to learn more about the future of telehealth.

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The Future of Telehealth in the U.S. and Across the Globe | InTouch Health

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Telehealth continues to grow at an accelerated rate around the world. The market is expected to grow at a CAGR of 14.9% over the forecast period 2019 to 2026 as more hospitals and healthcare facilities bring this technology online. Telehealth has the potential to reduce healthcare costs, improve patient outreach and health outcomes, and change the way providers treat their patients.

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-This Harvard article discusses the cons and pros of Telehealth
-It defines Telehealth as delivery of healthcare services through the use of technology
Pros:
-It allows health care providers to diagnose, treat, and     oversee their patients care
-Cost savings, convenience, care to patients with mobility challenges/limitations

CONS:
-Not all visits can be done remotely
-Secure transmission of health data electronically is still a concern
-Health insurance may not cover fully or charge same prices as an in person visit

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Normally, doctors and other health care providers care for their patients in person at a facility such as a medical office, clinic, or hospital. But thanks to computers, smartphones, and other new digital technologies, medical professionals can now diagnose, treat, and oversee their patients' care virtually.

Telehealth is defined as the delivery of health care services at a distance through the use of technology. It can include everything from conducting medical visits over the computer, to monitoring patients' vital signs remotely. Its definition is broader than that of telemedicine, which only includes the remote delivery of health care. Telehealth also includes the training and continuing education of medical professionals.

Telehealth can be delivered in one of three ways:

Synchronous-when the doctor communicates with the patient in real time via computer or telephone

Asynchronous-when data, images, or messages are recorded to share with the doctor later

Remote patient monitoring-when measurements such as weight or blood pressure are sent to the health care provider

Advantages of telehealth

Using technology to deliver health care has several advantages, including cost savings, convenience, and the ability to provide care to people with mobility limitations, or those in rural areas who don't have access to a local doctor or clinic. For these reasons, the use of telehealth has grown significantly over the last decade. Currently, 76 percent of hospitals in the U.S. connect doctors and patients remotely via telehealth, up from 35 percent a decade ago.

Telehealth has become even more essential during the coronavirus ( COVID-19) pandemic. Fears of spreading and catching the virus during in-person medical visits have led to a greater interest in, and use of, technology to provide and receive health care.

Almost three-quarters of Americans surveyed said the pandemic has made them more eager to try virtual care. And one in four Americans over age 50 said they'd had a virtual health care visit during the first three months of the pandemic, up from just four percent of older adults who'd had a remote visit the previous year.

What you can do with telehealth

All of the following activities and services are possible with the help of telehealth:

Recording measurements like your weight, food intake, blood pressure, heart rate, and blood sugar levels either manually, or through a wearable device, and sending them to your doctor.

Having a virtual visit with your doctor or a nurse over your computer or smartphone.

Using an online portal to check your test results, request prescription refills, send your doctor a message, or schedule an appointment.

Sharing information such as your test results, diagnoses, medications, and drug allergies with all of the providers you see.

Coordinating care between your primary care provider and any specialists you visit-including the sharing of exam notes and test results between medical offices in different locations.

Getting email or text reminders when you're due for mammograms, colonoscopies, and other screenings, or routine vaccinations.

Monitoring older adults at home to make sure they are eating, sleeping, and taking their medications on schedule.

Downsides to telehealth

Telehealth offers a convenient and cost-effective way to see your doctor without having to leave your home, but it does have a few downsides.

It isn't possible to do every type of visit remotely. You still have to go into the office for things like imaging tests and blood work, as well as for diagnoses that require a more hands-on approach.

The security of personal health data transmitted electronically is a concern.

While insurance companies are increasingly covering the cost of telehealth visits during the COVID-19 pandemic, some services may not be fully covered, leading to out-of-pocket costs.

Image: RichLegg/Getty Images

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Telehealth: The advantages and disadvantages - Harvard Health

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This article looks into how health information exchange can improve quality of care and lower cost. According to the writer, this is possible when and only if when more providers adopt data exchange tools. It is believed that HIE through programs such as HEALTHeLINK can improves quality of care, enhance patient safety, but most importantly reduce healthcare cost. Further, in New York they found that more than 96% of patients consented to have their information shared with other providers via HEALTHeLINK.

As a future provider, I believe that having access to a database that will allow me to exchange patient health information can allow me to give the best treatment options. It will also help me further reduce medical errors that can very easily happen when patients are transitioning from provider to provider or have a complex medical history where multiple providers are involved.

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-EHR have improved the way health records are accessed
-However it has come with a cost
-Potential to increase patient satisfaction, and reduce malpractice incidence
-Working on one day achieving Interoperability
-Benefits include: accessibility and potential to improve communication from physician-to-physician or physician-to-patient
-Help improve gathering health care records when needed; real time.

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Quick read on benefits and challenges experienced by health care workers with EHR

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SE Healthcare Data Analytics and Solutions

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Advances in technology like Electronic Health Records (EHRs) have changed the way the healthcare industry operates. In the years before EHRs, medical records were 100% paper-based documents.

In 2003, an article from the Journal of the American Medical Informatics Association explained that although paper record-keeping is simple, widely accepted, and only requires a low cost for implementation, healthcare can be improved by the use of electronic records. In fact, paper records hinder the healthcare environment due to limited accessibility, illegibility, inability to access files remotely, and the cost of storing immense files. By adopting EHRs, providers have organized and accessible records. They are also supported by practice improvement tools, such as computerized prescribing and ordering tools, to provide more efficient and safer patient care.

Decades after the introduction of EHRs, and despite the potential benefits they provide, physicians and dentists continue to have a difficult time adopting EHRs. To understand the challenges, it is important to understand both sides of the issue.

The Challenges

Physician Burnout

Physician burnout is a prevalent issue in the current healthcare landscape. About 50-60% of physicians are experiencing burnout. Burnout is associated with reduced patient safety, lower patient satisfaction, higher instances of malpractice claims, and can impact the work environment for team members.

Studies have shown that EHRs contribute to physician burnout due to the burdensome user interface. EHRs demand a substantial amount of time for clerical-type data entry. Working in EHRs, physicians spend less time on communication and valuable 1:1 time with patients. This contributes to lower job satisfaction, increased stress, and decreased quality of patient care.

Cost

The implementation of EHRs places a significant burden on both the practice and providers. EHRs are financially burdensome for practices; this is especially true for independent practices who do not typically have the same resources as larger health systems. Practices not only have to purchase the EHR software, but they often have to employ experienced IT staff for support and training. Training, and the learning curve associated with adopting EHRs, demands substantial time from physicians and staff - time that is taken away from patient care.

When staff have a difficult time adapting to or understanding the system, errors are more likely to occur. A tool that was originally developed to increase communication and quality of care may actually create a riskier healthcare environment.

Interoperability

Perhaps the largest problem with Electronic Health Records is the lack of interoperability between disparate systems. To have a full picture of a patient's medical history, it is important that systems are able to communicate effectively with each other.

Lack of interoperability - one of the biggest downsides of paper record-keeping - has yet to be effectively resolved with electronic record-keeping.

Despite these challenges, Electronic Health Records have the potential to provide value to the healthcare industry.

Benefits

Accessibility

Since EHRs are stored electronically, they can be accessed by different providers from different locations at different times. Providers are able to view the entirety of a patient's medical history, track treatment plans, and more efficiently plan the course of care.

In a life-threatening event, the accessibility of Electronic Health Records can be lifesaving. By viewing a patient's full medical history - allergies, blood type, past medical conditions - treatment decisions can be made quickly.

Improved Communication and Engagement

EHRs have the potential to improve communication between physicians and between physicians and patients. Although clerical demands can be burdensome, EHRs have the potential to facilitate communication that may not easily occur otherwise. EHRs help physicians to communicate with other providers and accurately track care and treatment plans between physicians.

Use of patient portals - web-based platforms within EHRs - allow patients to review their medical records, progress notes, medications, and radiology results. Many times, patients are highly motivated to become more actively engaged in their care and web portals allow a simple method to do so.

More communication necessarily leads to improved care. Electronic Health Records alleviate the problems of lost files and missed communications, which were more prevalent with paper-based methods of record-keeping. With the ability to view previous care plans, tests, and treatments, there is a lower chance of wasted time and resources repeating an unnecessary test or procedure.

There are many pros and cons of EHRs. As the healthcare industry continues to transform, these growing pains will ultimately resolve (if not replaced with new challenges). The steadfast focus, as always, should be reducing the clerical burden on providers of patient care while simultaneously improving safety, efficiency, communication, and patient engagement.

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The Benefits and Challenges of Electronic Health Records

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Advances in technology like Electronic Health Records (EHRs) have changed the way the healthcare industry operates. In the years before EHRs, medical records were 100% paper-based documents. In 2003, an article from the Journal of the American Medical Informatics Association explained that although paper record-keeping is simple, widely accepted, and only requires a low cost for implementation, healthcare can be improved by the use of electronic records.

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Quick form reviewing EHR and patients rights and privacy

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-Meaningful use began as a helpful approach with an incentive to pay physicians who made the transition to EHR and abide by all the guidelines that were set by the federal government.
-However, the federal government's initial guidelines left many physicians and institutions feeling trapped.
- Nevertheless, meaningful use can be helpful and continue in the future if the guidelines for the federal government continue to be reviewed

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https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.arkmed.org%2Fnews%2F2015%2F01%2Fwhat-cms-meaningful-use-changes-could-mean-for-physicians%2F&psig=AOvVaw3AOzSG5zyG5SMy9SherFe6&ust=1634427588854000&source=images&cd=vfe&ved=0CAsQjRxqFwoTCPDx3rbLzfMCFQAAAAAdAAAAABAD

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Quick read on meaningful use, what it is, and how it works

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Meaningful Use

To qualify for incentive payments through the Centers for Medicare & Medicaid Services EHR Incentive Programs, eligible providers and hospitals must demonstrate meaningful use of an electronic health record (EHR). In other words, "meaningful use" sets the specific objectives that eligible professionals and hospitals must achieve to participate in the EHR Incentive Programs.

Stages of Meaningful Use

The meaningful use objectives will evolve in three stages:

Stage 1 (2011-2012): Data capture and sharing

Stage 2 (2014): Advanced clinical processes

Stage 3 (2016): Improved outcomes

For More Information

For more information on meaningful use and how achieving meaningful use can help you improve health care quality and patient outcomes, see the following resources.

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To qualify for incentive payments through the Centers for Medicare & Medicaid Services EHR Incentive Programs, eligible providers and hospitals must demonstrate meaningful use of an electronic health record (EHR).

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-DIKW hierarchy describes data information knowledge wisdom.
-Data describes an entity or system objectively
-Information is the data we are going to organize or interpret
-Knowledge (interpreting, integrating, understanding) is understanding of the information  in hand and create relationship
-Wisdom is taking what is known and understand to then apply

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Great article addressing the epistemological aspects of data and knowledge with focus on the distinction between data, information, knowledge, and wisdom. It also investigates whether the infinite data is actually increasing human knowledge and wisdom.

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View of Revising the DIKW Pyramid and the Real Relationship Between Data, Information, Knowledge and Wisdom

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Return to Article Details Revising the DIKW Pyramid and the Real Relationship Between Data, Information, Knowledge and Wisdom

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Quick little read on the benefits to having EHR and HIE

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Interoperability allows for different information systems to communicate. There are four levels which include foundational, structural, semantic, organizational.

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What is Interoperability?

It is the ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.

Health data exchange architectures, application interfaces and standards enable data to be accessed and shared appropriately and securely across the complete spectrum of care, within all applicable settings and with relevant stakeholders, including the individual.

Four Levels of Interoperability

Foundational (Level 1): Establishes the inter-connectivity requirements needed for one system or application to securely communicate data to and receive data from another

Structural (Level 2): Defines the format, syntax and organization of data exchange including at the data field level for interpretation

Semantic (Level 3): Provides for common underlying models and codification of the data including the use of data elements with standardized definitions from publicly available value sets and coding vocabularies, providing shared understanding and meaning to the user

Organizational (Level 4): Includes governance, policy, social, legal and organizational considerations to facilitate the secure, seamless and timely communication and use of data both within and between organizations, entities and individuals. These components enable shared consent, trust and integrated end-user processes and workflows

What is Health Information Exchange and Data Sharing?

Health information exchange, or HIE, provides the capability to electronically move clinical information among disparate healthcare information systems and maintain the meaning of the information being exchanged. The goal of health information exchange is to facilitate access to and retrieval of clinical data to provide safe, timely, efficient, effective and equitable patient-centered care. HIE can also be used by public health authorities to assist in the analysis of the health of populations.

The term HIE is generally used as either a verb or a noun.

Verb: The electronic sharing of health-related data between two or more organizations facilitated by applied standards for use by a variety of stakeholders to inform health and care.

Noun: Organizations within the United States that provide health information exchange technology and services at a state, regional or national level and often work directly with communities to promote secure sharing of health data.

In the European Union, the act of information exchange is often referred to as data sharing. The European Commission's Support Centre for Data Sharing uses the term to refer to the collection of practices, technologies, cultural elements and legal frameworks that are relevant to transactions in any kind of information digitally, between different kinds of organizations. This term is more broadly applied to all types of data sharing, but can also be specifically used for health-related data.

Interoperability Standards

Standards provide a common language and a common set of expectations that enable interoperability between systems and/or devices. In order to seamlessly digest information about an individual and improve the overall coordination and delivery of healthcare, standards permit clinicians, labs, hospitals, pharmacies and patients to share data regardless of application or market supplier.

Standards Development

A standards organization, standards body, standards development organization (SDO) or standards setting organization is focused on developing, coordinating, promulgating, revising, amending, reissuing, interpreting, or otherwise producing standards that are intended to address the needs of some relatively wide base of affected adopters.

In order to be recognized as an SDO, an organization may be accredited by the American National Standards Institute (ANSI) or the International Organization for Standardization (ISO). Standards are also developed by other groups such as trade unions or associations. The development and adoption of open, consensus-based standards can be a complex process involving many different stakeholders and subject matter experts.

There are over 40 different SDOs in the health IT arena. Some entities create standards, such as Health Level Seven (HL7), Systematized Nomenclature of Medicine (SNOMED) International, and the Clinical Data Interchange Standards Consortium (CDISC). Others, like Integrating the Healthcare Enterprise (IHE), do not develop new standards, but rather bundle complementary base standards into IHE profiles that are used to define a specific function or use case, and then are balloted. This creates a scenario that helps drive adoption of the base standards by providing implementation guidance that describes how multiple standards can be used together to support interoperable health information exchange.

The different SDOs and profiling organizations have varying compositions and processes, but generally follow shared principles based on developing standards through a multi-stakeholder, consensus-based process to respond to specific industry or market needs.

Types of Standards

In order to understand the types of health data standards available for use, informatics professionals organize these standards into the following specific categories: vocabulary/terminology, content, transport, privacy and security, and identifiers.

Vocabulary/Terminology Standards

Vocabulary/terminology standards address the ability to represent concepts in an unambiguous manner between a sender and receiver of information, a fundamental requirement for effective communication. Health information systems that communicate with each other rely on structured vocabularies, terminologies, code sets and classification systems to represent health concepts. Some common vocabulary standards currently used in the marketplace include:

Current Procedural Terminology (CPT®): A code set, maintained by the American Medical Association (AMA), used to bill outpatient and office procedures.

Healthcare Common Procedure Coding System: A set of healthcare procedure codes based on CPT that is used for Medicare reimbursement.

ICD-10 and ICD-11: The International Statistical Classification of Diseases and Related Health Problems (ICD) is a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The 11th revision will replace the ICD-10 in January 2022.

Logical Observation Identifiers Names and Codes (LOINC®): A universal code system for identifying health measurements, observations and documents. These codes represent the "question" for a test or measurement. LOINC codes can be grouped into laboratory and clinical tests, measurements and observations.

National Drug Code (NDC): Maintained by the U.S. Food and Drug Administration, NDC provides a list of all drugs manufactured, prepared, propagated, compounded or processed for commercial distribution.

RadLex: A unified language of radiology terms for standardized indexing and retrieval of radiology information resources, managed by the Radiological Society of North America. It unifies and supplements other lexicons and standards, such as SNOMED-Clinical Terms and DICOM.

RxNorm: A terminology used to normalize names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.

Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT): A comprehensive clinical health terminology product. It enables the consistent, processable representation of clinical content in electronic health records (EHRs). These codes often represent the "answer" for a test or measurement to the LOINC "question" code.

The Centers for Disease Control and Prevention (CDC) provide a number of code sets for vaccines (Vaccines Administered (CVX)) and manufacturers (Manufacturers of Vaccines (MVX)). These codes can be used in immunization messages.

The Unified Code for Units of Measure: A code system intended to include all units of measures used in international science, engineering and business to facilitate unambiguous electronic communication of quantities together with their units.

Content Standards

Content standards relate to the data content within exchanges of information. They define the structure and organization of the electronic message or document's content. This standard category also includes the definition of common sets of data for specific message types.

Consolidated CDA (C-CDA): A library of CDA templates, incorporating and harmonizing previous efforts from HL7, IHE, and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination and Continuity of Care Documents, or CCD.

HL7's Version 2.x (V2): A widely implemented messaging standard that allows the exchange of clinical data between systems. It is designed to support a central patient care system as well as a more distributed environment where data resides in departmental systems.

HL7 Version 3 Clinical Document Architecture (CDA®): An XML-based document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange between healthcare providers and patients. It defines a clinical document as having the following six characteristics: persistence, stewardship, potential for authentication, context, wholeness and human readability.

Transport Standards

Transport standards address the format of messages exchanged between computer systems, document architecture, clinical templates, user interface and patient data linkage. Standards center on "push" and "pull" methods for exchanging health information.

Digital Imaging and Communications in Medicine (DICOM): The standard for the communication and management of medical imaging information and related data. DICOM enables the transfer of medical images across systems and facilitates the development and expansion of picture archiving and communication systems.

Direct StandardTM: Defines a set of standards and protocols to allow participants to send authenticated, encrypted health information directly to known, trusted recipients over the internet. Two primary specifications are the Applicability Statement for Secure Health Transport v1.2 and the XDR and XDM for Direct Messaging.

Fast Healthcare Interoperability Resources (FHIR®): An HL7 standard for exchanging healthcare information electronically. The basic building blocks of FHIR are "resources," which describe exchangeable health data formats and elements. FHIR also provides standardization for application programming interfaces (APIs). FHIR provides a number of benefits and improvements as a modern healthcare standard including facilitating interoperable exchange with legacy standards, lower overhead, shorter learning curve, an ability to transmit only the necessary pieces of information, potential for patient mediated data, and an energized community of supporters and implementers.

IHE provides a number of specifications that can be used in the exchange of health information.

PCHAlliance co-sponsors the Personal Health Device (PHD) efforts within the IHE Devices Domain, which are focused on developing IHE profiles that leverage and build upon the Continua Design Guidelines and are also updated to support FHIR. These profiles provide guidance to implement globally recognized, consensus-based approaches to connect and test both personal and clinical devices and integrate them into health information systems. The specifications being developed support both medical devices and mainstream consumer facing apps to enable scalable interoperability of the rapidly expanding connected health ecosystem.

Privacy and Security Standards

Privacy standards aim to protect an individual's (or organization's) right to determine whether, what, when, by whom and for what purpose their personal health information is collected, accessed, used or disclosed. Security standards define a set of administrative, physical and technical actions to protect the confidentiality, availability and integrity of health information.

In the U.S., the Health Insurance Portability and Accountability Act (HIPAA) outlines standards that safeguard the privacy and security of protected health information.

HIPAA Privacy Rule: Establishes national standards to protect individuals' medical records and other personal health information. It applies to health plans, healthcare clearinghouses, and healthcare providers that conduct certain healthcare transactions electrically. The rule applies safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures of such information without patient authorization. The rule also gives patients rights over their own health information, including the right to examine and obtain a copy of their records, and to request corrections.

HIPAA Security Rule: Sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information. Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans). The rule addresses the technical and non-technical safeguards that "covered entities" must have in place to secure an individual's electronic protected health information. Prior to HIPAA, there were no generally accepted requirements or security standards for protecting health information.

In Europe, the General Data Protection Regulation (GDPR) outlines privacy and security regulations for all processing and storage of data relating to data subjects-or people-in the European Union (EU). This regulation extends to health information and any organization that may process or store data on these subjects, meaning it has extensive reach to many organizations worldwide and related to the sharing of data across organizations.

Identifier Standards

Entities use identifier standards to uniquely identify patients or providers.

Enterprise Master Patient Index (EMPI): A data registry used across a healthcare organization to maintain consistent and accurate data on the patients treated and managed within its departments.

Medical Record Number (MRN): An organization specific code used as a systematic documentation of a patient's history and care during a hospital stay.

National Council of State Boards of Nursing ID (NCSBN ID): A unique identifier automatically generated for each registered nurse and licensed practical/vocational nurse, freely available via the Nursys database and maintained by NCSBN.

National Provider ID (NPI): A unique 10-digit number for a healthcare provider to create a standard identification. These NPIs are included in the free NPI Registry.

Object ID (OID): A globally unique ISO identifier and a preferred scheme for unique identifiers in HL7.

Standards, Implementation Guides and Profiles

Standards on their own are helpful because they describe and constrain what data moves.

Implementation guides describe how to implement these standards for a specific use case. An implementation guide is a companion to a standard that describes how to use a standard to satisfy a specific healthcare use case. It should specify which way a standard is to be applied in a particular use case-how to structure the data consistently and what vocabulary to use. While you can implement a standard in a number of different ways, when using an implementation guide to integrate a standard into a health IT system, the guide directs one way to constrain the standard for a particular situation, removing ambiguity and achieving consistency.

A benefit to the use of implementation guides like IHE Profiles is that they provide a common language for purchasers and market suppliers to discuss the integration needs of healthcare sites and the integration capabilities of health IT products. They provide precise definitions of how to implement standards to meet specific clinical needs. They offer developers a clear implementation path for standards that has been carefully documented, reviewed and tested as well as supported by industry partners. They give purchasers a tool that reduces the complexity, cost and anxiety of implementing interoperable systems. IHE profiles, in particular, organize and leverage the integration capabilities that can be achieved by coordinated implementation of communication standards, such as DICOM, HL7 W3C and security standards.

Testing and Conformance Efforts

The adoption and implementation of standards involves a testing ecosystem that spans standards development, implementation and feedback from real-world testing into the development process to support continuous improvement. There are various different testing and compliance efforts that support advancing health IT interoperability, including:

Conformity Assessment: IHE International administers the IHE Conformity Assessment Scheme, which forms the basis for IHE Conformity Assessment Programs and any official certification of conformance to IHE Profiles associated with such testing programs. IHE International authorizes designated test laboratories accredited under this standard to assess the conformity of products with selected IHE profiles.

eHealth Exchange Testing Program: The program was developed to test compliance for HIE standards as required by the eHealth Exchange Coordinating Committee for onboarding to the eHealth Exchange network. Its purpose is to enable organizations that wish to participate in the exchange to validate the compliance of their health IT with the eHealth Exchange Performance and service specifications.

HL7 FHIR® Connectathons: These events provide hands-on FHIR development and testing opportunities held in conjunction with working group meetings. Participants engage in development and testing, working directly with other FHIR developers and senior members of the FHIR standards development team.

IHE Connectathons: A cross-vendor, supervised and structured testing event where the industry tests implementation of IHE Profiles and other standards to successful standards implementation and use. All tests are evaluated on interoperability and conformance to IHE Profiles found in IHE's technical frameworks. The test floor is overseen by IHE's technical project managers, providing a safe, neutral test environment and an opportunity for industry collaboration and problem resolution.

Office of the National Coordinator for Health IT Health IT Certification Program: A voluntary certification program established by the Office of the National Coordinator for Health IT (ONC) to provide for the certification of health IT. Requirements for certification are established by standards, implementation specifications and certification criteria adopted by the ONC secretary. The program supports the availability of certified health IT for its encouraged and required use under other federal, state and private programs. The program is run as a third-party product conformity assessment scheme for health IT based on the principles of the ISO and International Electrotechnical Commission framework.

Organizations like the Global Consortium for eHealth Interoperability, which was co-founded by HIMSS, IHE International and HL7 International, work to amplify and align the work of organizations like IHE and HL7 to increase adoption of emerging and mature health IT standards. The primary goal of the consortium is to coordinate work with governments and national ministries of health to further align existing and emerging standards and implementation guidance with strategic healthcare policy goals to achieve improved health outcomes for people everywhere.

The Interoperability Ecosystem

The health interoperability ecosystem comprises individuals, systems and processes that want to share, exchange and access all forms of health information, including discrete, narrative and multimedia. Individuals, patients, providers, hospitals/health systems, researchers, payers, suppliers and systems are potential stakeholders within this ecosystem. Each is involved in the creation, exchange and use of health information and/or data.

An efficient interoperability ecosystem provides an information infrastructure that uses technical standards, policies and protocols to enable seamless and secure capture, discovery, exchange and utilization of health information.

Exchange Partners and Data Sources

Historically, the focus was on the exchange of clinical information between providers and hospitals. As the technology has progressed, these exchange partners have broadened to include individuals, such as patients and caregivers, and organizations, such as long-term care, public health departments, community-based organizations and payers. With this expansion, along with the shift to value-based care, has also come a broader range of data types that are available to inform health and care, including device data, patient-generated data and data pertaining to the social determinants of health. Social determinants of health can include data points such as an individual's housing status, access to reliable transportation and level of food security.

Network Architectures

There are three primary types of exchange network architecture used to coordinate the exchange of health information across entities.

Centralized: Patient data are collected and stored in a centralized repository, data warehouse or other databases. The exchange organization has full control over the data, including the ability to authenticate, authorize and record transactions among participants.

Federated (Decentralized): Interconnected but independent databases allow for data sharing and exchange, and grant users access to the information only when needed.

Hybrid: Incorporates variations of federated and centralized architectures to harness the advantages of both. These are becoming common as various combinations of available services are implemented.

An important technical development that has expanded exchange partners and data sources is the emergence of healthcare APIs. APIs outline a set of clearly defined specifications to allow for one software application to build on the data and functionality of another application, without needing to understand its system design. APIs are already ubiquitous in today's web economy, and will play an essential role with respect to fueling healthcare interoperability for person centered care.

Types of HIE Organizations

An HIE organization oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. The purpose of a health information exchange organization is to perform oversight and governance functions for information exchange. There are several different types of HIEs currently operating across the U.S. and its territories:

1. Hybrid HIEs are often collaborations between organizations, such as an ACO and a vendor network, within a state or region. The Kentucky Health Information Exchange is an example of a hybrid model.

2. Private/Proprietary HIEs concentrate on a single community or network, often based within a single organization, and include overall management, finance and governance. Examples may include hospital/integrated delivery system networks, payer-based HIEs and disease-specific HIEs. Some software vendors have also established an HIE network for their clients across the U.S. Additionally, the industry may see other evolving entities such as Accountable Care Organizations (ACOs) supporting information exchange.

3. Regional/Community HIEs are inter-organizational and depend on a variety of funding sources. Most are not-for-profit. Indiana Health Information Exchange and Chesapeake Regional Information System for Our Patients are examples of a regional HIEs.

4. State-wide HIEs are run by the governments of their respective states or maybe the state's designated entity. Some state-wide (and regional) HIEs use an umbrella approach and serve as the aggregator for disparate private health information exchanges. Statewide Health Information Network for New York and Arizona's Health Current are examples of a state-wide HIEs.

U.S. Exchange Initiatives: An Environmental Scan

Many organizations are actively working to achieve ubiquitous exchange. This environmental scan provides a curated review of the current landscape of the U.S.-based networks and frameworks which enable interoperable, nationwide health information exchange via a variety of methods and collaborations.

International Networks Enabling Exchange

Beyond the examples outlined above, various exchange networks and infrastructure have been established globally.

The eHealth Digital Service Infrastructure (EHDSI) facilitates the two primary building blocks of cross-border digital health services in Europe: ePrescription and Patient Summary. ePrescription (and eDispensation) allows EU citizens to obtain their medication in a pharmacy located in another EU country. Patient Summary provides information on important health related aspects such as allergies, current medication, previous illness, surgeries, etc. The digital Patient Summary is meant to provide doctors with essential information in their own language concerning the patient, when the patient comes from another EU country and there may be a linguistic barrier.

An important precursor of major exchange initiatives in Europe have been the European Reference Networks. These are virtual networks involving healthcare providers across Europe. They aim to facilitate discussion on complex diseases and conditions that require highly specialized treatment, providing concentrated knowledge and resources. Coordinators convene virtual advisory panels of medical specialists across different disciplines, using a dedicated IT platform and telemedicine tools.

Argentina's National Interoperability Network uses standards to enable communication between participating health information systems, providing a bridge for identity management across systems, sharing documents and patient summaries, managing ePrescriptions and supporting national registries.

Australia's My Health Record is an opt-out, CDA-based document repository used to store shared health summaries, eReferrals, specialist letters, discharge summaries, event summaries, prescription records, diagnostic imaging and pathology reports. Once patients have their record, they are able to manage access and permissions.

Canada's Health Infoway manages an ePrescribing service, PrescribeIT, electronically shares prescription information from clinicians with pharmacies for dispensing. Another Infoway initiative, ACCESS Health, aims to accelerate citizen access to personal health information and digital health services. The exchange initiative is expected to use a cloud-based infrastructure, a FHIR-based API service and a blockchain-enabled consent service.

Hong Kong's Electronic Health Record Sharing System is the country's equivalent to a regional HIE, managing patient data on care episodes, lab results, radiology studies and drug items. The Hong Kong Hospital Authority launched eHRSS to public and private health sectors using an opt-in patient consent model.

Uses of Information Exchange
Watch the HIMSS TV deep-dive on interoperability.
Ultimately, the goal is to be able to share and access information that informs an individual's full, longitudinal health story. By having and understanding the complete and accurate picture of an individual's health-including their preferences and other determinants of health-includes a number of benefits. Clinicians can better inform care and decision making, patients can become active participants in their care plans, and health IT developers and implementers can leverage evidence to create and adopt systems that support clinical processes and improve care delivery.

A number of benefits can be realized for exchange stakeholders, including:

1. Care coordination: Care coordination often involves a variety of stakeholders, including patients, caregivers and care teams across settings in the management of a patient's health. This is a dynamic process that requires data movement across platforms and among service providers in real time to successfully manage care.

2. Improving business and administrative processes: Having access to health information can eliminate time-consuming tasks within a health system, including processing of intake information, coordination across care teams and reporting needs associated with various regulatory requirements.

3. Increased patient safety and satisfaction: Having a full picture of a patient's health through access to disparate data can better inform clinicians on the patient's medical history, preferences and past encounters. This can help avoid duplicate testing, reduce adverse events, inform care decisions and conduct appropriate follow-up to ensure adherence with care management.

4. Value-based care: Population-level data analysis is an essential component of health systems managing high-risk patient populations, public health systems and other stakeholders working to coordinate care needs for a community. Understanding population data can enable better risk analysis and more cost-effective care. At an individual level, having access to longitudinal health data on a patient can reduce duplicative testing and close gaps in information. A key consideration in the shift to value-based care is the incorporation of non-traditional health data, such as an individual's social determinants of health data (e.g. food security status, housing stability and access to reliable transportation) into patient records. This data can be leveraged by health systems to proactively identify a health risk within a target population and intervene to work toward positive outcomes.

With these benefits in mind, taking a use-case driven approach can frame how information sharing may inform care or business practices and can help frame the potential benefits and drive interoperability forward. The following examples provide a snapshot at how interoperable exchange may occur.

Care delivery data: A physician can query a network or external health system for the appropriate patient data from other sources, such as other clinicians and hospitals. The physician can then select certain patient documents or resources (such as medication lists and reconciliations, allergy lists or lab reports) that they want to access during a patient visit.

Consent management: Where consent is not governed by other laws or regulations, a centralized consent management process can enable consensus among the community's stakeholders for a patient consent model, and provide awareness of a patient's willingness to participate in data sharing activities.

Lab results: HIE services provide physicians with the ability to get results directly via their exchange networks.

Medication reconciliation: Having a longitudinal view of all of a patient's encounters can raise awareness of the potential medications a patient was previously or is currently using. This can allow for appropriate follow up with the patient to reconcile differences in records to produce an accurate picture of their medication lists for future encounters.

Patient intake: Using a query and response process, the patient's health record can be acquired ahead of an appointment for clinician review.

Patient preferences: Exchange networks can enable access to information about a patient's care preferences, such as advance directives, empowering patients to make decisions in their care.

Provider alerts: HIE organizations are able to provide alerts to a clinician on their patients when one presents to the emergency department or is admitted to or discharged from a hospital, to ensure appropriate follow-up can be conducted.

Query services: Physicians may want to obtain more information about a patient that is referred to their office. They can query an exchange network which can in turn query other networks or health systems to assemble a complete, longitudinal health record.

Record locator services/master patient indexes: Many exchange networks enable creation of one continuous community record or search capabilities for patient records, facilitating patient identification across multiple provider settings.

Referrals: Organizations have the ability to send referrals directly through HIE services, along with all appropriate documentation.

Secure messaging: Many use cases require the exchange of patient records or related health information between clinicians in different healthcare settings with different EHRs or IT systems. For instance, providers needing to send referrals can electronically share data, eliminating paper documents and expediting the patient's treatment.

Transitions of care: As patients make the transition from one care setting to another (such as from hospital to a primary care provider or skilled nursing facility), interoperable exchange of relevant documentation from one care setting can be easily accessed at the next.

Workflow Considerations and Guidance

As the HIMSS definition suggests, interoperability goes beyond its technical requirements. Often there are policy changes influencing the value proposition and therefore willingness to exchange. Organizational considerations must align with external organizations and work toward achieving trust across stakeholders to enable meaningful data sharing. The following outlines some of these considerations and the approaches that may be leveraged.

Obtaining Patient Consent

Ensuring and communicating patient consent for data sharing activities is critical to abide by regulatory requirements and maintain the trust of the patient. There are several consent models used in information exchange, dependent on regulatory requirements within a jurisdiction.

No consent: Patient health information at a participating healthcare organization is automatically included in and available for exchange.

Opt-in: No patient data sets are made available for electronic exchange until patients actively express whether they would like to make all, or a pre-defined set, of their information available.

Opt-in with restrictions: No patient data sets are made available for electronic exchange until patients actively give their consent to participate. Patients have the option to:

Allow information to flow only to specific providers/li>

Include only specific categories of data or data elements

Make all of their information available for exchange

Opt-out: All or some predefined data sets are qualified to be included and available for exchange, after patients are given the opportunity to opt out in full.

Opt-out with exceptions: All or some predefined data sets are qualified to be included and available for exchange after patients are given the opportunity to:

Allow the exchange of their information only for specific purposes

Limit exchange of their information only for specific purposes

Limit exchange of their information to specific providers or provider organizations

Opt out in full

Selectively exclude categories of data or specific data elements from the exchange

Regardless of the model leveraged, a patient has the right to revoke their consent at any time, and processes to ensure that preference is communicated and enforced is important for data sharing processes.

Ensuring Privacy and Security

Regulations such as GDPR in the EU, HIPAA in the U.S., and various other national and state laws and regulations set forth privacy and security requirements to safeguard health information when it is created, received, transmitted, or maintained by health systems and other organizations. Privacy and security considerations may include the following:

Executing and implementing data use and reciprocal support agreements (DURSA)-also known as trust agreements-with the health systems and other stakeholders. These agreements set forth who may access and exchange the data. Additionally, such agreements set forth standard privacy and security policies and procedures that govern data protection and use. Further, data is typically encrypted when data is exchanged from one organization to another.

While specific security requirements may differ depending upon the DURSA, a typical DURSA may call for each participant to maintain appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and availability of the data, aligned with the HIPAA requirements and any other applicable laws and/or regulations.

Producing High-Quality Data

In order to ensure that the information received from disparate sources can be trusted that it is accurate and complete, there needs to be efforts by organizations to maintain high-quality data. This can be achieved by ensuring that:

1. Data are structured and coded with standardized terminology and styles where possible to be leveraged in a machine-readable format for analysis and interpretation

2. Documentation is robust and complete to communicate the full patient story in a way that provides meaning to the human end user of the information.

Public Policy and Government Efforts

Achieving interoperability to date has required government involvement, guidance and regulation. Public policy efforts have the potential to drive forward frameworks for trusted exchange, align and educate stakeholders on existing and emerging standards and broaden stakeholder participation to ensure an inclusive exchange ecosystem for care coordination and continuity. The following outlines examples of how governments have worked to facilitate exchange both within the U.S. and in countries around the world.

United States Policies and Initiatives

With the goal of achieving ubiquitous, interoperable, nationwide exchange, the U.S. Department of Health and Human Services (HHS) has enacted and implemented a variety of legislation, regulations and guidance to further the adoption of standards-based approaches to interoperability.

21st Century Cures: Key Provisions

Among the health IT provisions outlined in 21st Century Cures, many sections provide directives to the ONC, Centers for Medicare and Medicaid Services (CMS) and other agencies related to improving interoperability.

The draft Trusted Exchange Framework and Common Agreement includes the policies, procedures and technical standards that build from existing health information network capabilities and enables them to work together to provide that single on-ramp to electronic health information regardless of the developer, health information exchange, or where a patient's records are located.

The U.S. Core Data for Interoperability is a "standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange." A "Data Class" is an "aggregation of various Data Elements by a common theme or use case."

The ONC Interoperability and Information Blocking Final Regulation implements key provisions of the 21st Century Cures Act focused on advancing interoperable exchange; supporting the access, exchange and use of electronic health information; and addressing occurrences of information blocking. The rule calls for accelerated use of healthcare APIs. ONC Certified Health IT must have standardized APIs for patient and population services, and meet specific requirements called out in the API Conditions and Maintenance of Certification. Most importantly, the regulation requires that United States Core Data for Interoperability is available for healthcare providers and patients "without special effort."

The Cures Act tasks ONC with the creation of an EHR Reporting Program as a condition of their certification and maintenance of certification. ONC has a process to solicit feedback from the industry on what criteria and methods of collection should be explored for this program. The program's reporting criteria aims to address the following five categories: security, interoperability, usability and user-centered design, conformance to certification testing, and other categories as appropriate to measure the performance of certified EHR technology.

In parallel with the release of the ONC Interoperability and Information Blocking Final Regulation, CMS also outlined an Interoperability and Patient Access Final Regulation, as part of their MyHealthEData Initiative, focused on driving exchange of and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage, Medicaid, Children's Health Insurance Plan, and Qualified Health Plan issuers on the federally facilitated exchanges.

Interoperability Standards Advisory

The Interoperability Standards Advisory (ISA) process represents a single, public list of standards and implementation specifications published by ONC. ONC coordinates the identification, assessment and determination of these recommended standards and implementation specifications for industry use to fulfill specific clinical health IT interoperability needs. Stakeholders are encouraged to implement and use these recommended standards as applicable to their needs.

The ISA is organized into sections with related interoperability needs, each including one or more standards or implementation specifications to accomplish the listed need. Additional characteristics on these standards and implementation specifications are listed to inform stakeholders on maturity and adoption. These include:

1. Adoption Level: Approximate, average adoption level for that specific use case in healthcare within the United States.

2. Cost: Conveys whether a fee is involved to purchase, license, or obtain membership for access or use of the recommended standard or implementation specification.

3. Federally Required Status: Conveys whether a standard or implementation specification has been adopted in regulation, referenced as a federal program requirement, or referenced in a federal procurement (i.e., contract or grant).

4. Implementation Maturity: Conveys maturity based upon its implementation state.

5. Standards Process Maturity: Conveys maturity in terms of its stage within a particular organization's approval/voting process.

6. Test Tool Availability: Conveys whether a test tool is available to evaluate health IT's conformance to the standard or implementation specification.

Advancing Standards for Precision Medicine

This ONC project aims to standardize data found outside of traditional care delivery settings. As part of the precision medicine initiative, it focuses on standards in two areas:

1. Mobile health, sensor and wearable data

2. Social determinants of health data

Interoperability Proving Ground

ONC hosts an open, community platform where individuals and organizations can share and learn from projects occurring in the United States and internationally.

Data: Elemental to Health Campaign

HIMSS and PCHAlliance strongly urge prioritization of necessary funding and technical assistance to implement modern health information and technology strategies to ensure timely interoperability and sharing of public health surveillance data. An important component is the work in partnership with the Association of Public Health Laboratories, Council of State and Territorial Epidemiologists and the National Association for Public Health Statistics and Information Systems that support this multi-year effort to modernize public health data systems, surveillance and analytics at the CDC, and state, local and tribal health departments. Funding included in the Fiscal Year 2020 Appropriations Package and the Coronavirus Aid, Relief and Economic Security (CARES) Act, will help address some of the challenges, but in the long term, we need a predictable and sustained funding source to fully tackle this issue.

State-Level Interoperability Initiatives

In the U.S., state public health agencies manage and track information for immunizations, infectious diseases and vital statistics, however, they often lack adequate funding to ensure their information systems are updated and conform to national standards and profiles. Health information exchanges -which are public or private entities, depending on the state and region-aim to ensure there is robust and standardized data exchange between and among public health entities and state and local health departments.

Global Governmental Policies and Initiatives

At an international level, there are a variety of initiatives being led by health ministries and governments to further country-level and cross-border interoperability efforts.

The Global Digital Health Partnership (GDHP) is a collaboration of over 40 governments and territories, government agencies and the World Health Organization, formed to support the effective implementation of digital health services. Interoperability is one of the various work streams explored by GDHP. The proposed work stream activities focus on the evolving challenges of sharing patient data between care providers, organizations, caregivers and patients. These challenges are partly a technical problem for health systems, clinicians and patients, however they also pose significant risks for patient safety, and detract from high-quality coordinated care and the efficient delivery of services. A GDHP report outlines a variety of government efforts from 15 participating countries.

In Europe, the EU EHR Exchange Format developed the EU's eHealth Network to support the digital transformation of health and care in the EU by seeking to unlock the flow of health data across borders, and support implementation of the Cross-Border Health Care Directive. The recommendation seeks to facilitate the cross-border exchange of EHRs in the EU by supporting member states in their efforts to ensure that citizens can securely access and exchange their health data wherever they are in the EU. It will help citizens to quickly access and share their health data with healthcare professionals, for example, when consulting a specialist or receiving emergency treatment in another EU country.

The backbone infrastructure for the EHR exchange is the EHDSI. The EHDSI consists of services and infrastructure that use information and communication technologies to enable cross-border healthcare services. Initial focus is on enabling the exchange of baseline health information, including:

ePatient Summary to provide access to verified key health data of a patient during an unplanned care encounter while abroad

ePrescriptions to enables patients to receive equivalent medication treatment while abroad to what they would receive in their home country

A number of EU countries are already exchanging the ePatient summaries and ePrescriptions. As part of the EHDSI, Finland and Estonia were among the first to implement infrastructures to support the exchange of patient summaries, leveraging the X-Road platform, a free and open-source data exchange layer solution that enables organizations to exchange information securely over the internet. Future phases will include lab results, medical imaging and reports, and hospital discharge letters.

The European Commission also outlined priorities for 2019-2024 EU Digital Strategy, which included the creation of a European Health Data Space (EHDS) to foster the exchange and sharing of different kinds of health data (electronic health records, genomics, registries, etc.) in Europe. It aims to not only support exchange for the delivery of primary care, as well as, the development of new treatments, medicines, medical devices and services. Beyond the citizens, this would help meet the needs of different users and actors in the health system, while simultaneously protecting citizens' data. The commission is currently working with the member states and stakeholders to define the best governance structure and set up the appropriate infrastructure for the EHDS. Additionally, some existing regulatory gaps regarding member states implementation of the GDPR for the secondary use of data are being addressed.

The European Interoperability Framework (EIF) gives specific guidance on how to set up interoperable digital public services. It offers public administrations 47 concrete recommendations on how to improve governance of their interoperability activities, establish cross-organizational relationships, streamline processes supporting end-to-end digital services, and ensure that both existing and new legislation do not compromise efforts.

In an effort to ensure secure and federated access to genomic data, the European 1+ Million Genomes Initiative aims to create a technical infrastructure to improve disease prevention, allow for more personalized treatments and provide a sufficient scale for new clinically impactful research. In addition to the technical foundation for this effort, the signatory countries will also assess ethical and legal implications of genomics, and data storage, security and ethical uses.

Beyond these broader initiatives occurring across Europe, many countries are also leading specific regional and national efforts to expand exchange abilities./p>

The Nordic Interoperability Project is a consolidated grassroots effort to demonstrate the value for the patient from a seamless cross-border exchange of health data. The consortium includes organizations from all five Nordic countries-Denmark, Finland, Iceland, Norway, Sweden-and works to enable patients to live and act in an open, seamless, cross-border healthcare ecosystem, by showcasing and implementing solutions and innovations from the Nordics. The goal is to enable the Nordics by 2030 to be the most sustainable and integrated health region in the world, providing personalized healthcare for all its citizens.

In Portugal, the Shared Services of the Ministry of Health (SPMS) is a state-owned enterprise that manages the Portuguese Health Ministry Central Purchasing and serves as the national IT authority and the Portuguese representative for eHealth cross-border affairs. SPMS provides shared services in the areas of purchasing and logistics, financial services, human resources, and information and communication technologies to health and care entities to centralize and optimize the procurement of goods and services within the Portuguese National Health System.

In Asia and the South Pacific, many governments are also adopting digital health strategies to encourage interoperable exchange. For example, India's The Ministry of Health and Family Welfare (MoHFW) publishes EHR standards and created a Centre for Health Informatics under the eHealth Division of MoHFW as part of their Digital Health Strategy to initiate several digital health initiatives in the country, and started the National Health Portal as a citizen portal with the objective of improving the health literacy of the masses in India. New Zealand's health agencies, organizations and individuals signed a Commitment to New Zealand Health Interoperability to outline principles to drive the adoption of exchange infrastructures and processes in their health sector.

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Discover key insights about interoperability and better understand how data sharing can make a difference in healthcare.

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It is incredible to read about what nurses have done outside of the bedside. Nurses have truly have helped built, improve, and sustain the healthcare technology infrastructure!

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Department: Nursing Informatics

Sally E. Schlak is the senior director of the TIGER Initiative Foundation and Michelle Troseth is chief professional practice officer at Elsevier's CPM Resource Center.

The authors have disclosed that they have no financial relationships related to this article.

When the Office of the National Coordinator for Health Information Technology (ONC) held its first meeting announcing the federal strategic framework for the "Decade of Health Information Technology" in 2004, it was more than a bit disconcerting that there was no mention of nurses and the impact nurses would make not only achieving the national goals, but also improving and sustaining a new healthcare technology infrastructure. With the nation's 3 million nurses-who comprise up to 55% of the healthcare workforce-not represented and/or clearly not identified as an integral part of achieving the ONC vision and strategy, a sense of urgency grew. Soon, the Technology Informatics Guiding Educational Reform (TIGER) Initiative was born.

Commitment to health IT

The TIGER Initiative brings together a diverse group of stakeholders to develop a shared vision, strategies, and specific actions for improving nursing practice, education, and patient-care delivery through the use of health information technology (IT). An invitational TIGER Summit was held in 2006, during which a 10-year vision and 3-year action plan were developed to engage nurses in the revolution of evidence and informatics in healthcare. With support from over 70 contributing organizations, and a grant from the Robert Wood Johnson Foundation, the TIGER Initiative emerged with over 1,500 volunteers, in many collaborative working groups, addressing the prioritized areas identified during the TIGER Summit.

In 2011, the TIGER Initiative Foundation was formed, an organization operating for charitable, educational, and scientific purposes. One of the initial undertakings of the TIGER Initiative Foundation board of directors was to refresh the TIGER vision and create a guiding mission statement. The new TIGER Initiative vision is to "enable nurses and interprofessional colleagues to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient-centered, timely, and equitable by interweaving evidence and technology seamlessly into practice, education, and research, fostering a learning healthcare system." The TIGER Initiative mission is "advancing the integration of health informatics to transform practice, education, and consumer engagement."

The TIGER Initiative board has instituted three committees to carry out this vision and mission:

1. Foundation Development Committee, to support the funding and sustainability of the TIGER Initiative as a new nonprofit entity.

2. Education Committee, to continue the advancement of education for academic and practice settings related to informatics, as well as launch a virtual learning environment (which was identified as a critical need for clinicians, educators, and managers to have access to best practices related to health IT and diverse learning modules/resources to advance knowledge and widespread adoption).

3. Interdisciplinary and Community Engagement Committee, to engage interprofessional colleagues and consumers to be representative of all health professions and patients/families in further advancing the integration of health informatics to achieve true transformation.

One step in that direction was when the ONC launched a nationwide campaign in September 2011 to educate and engage the public on the value and benefits of health IT. The TIGER Initiative Foundation supports the ONC's Consumer eHealth Program and has pledged to:

develop a well-trained nursing and interprofessional workforce to empower and foster consumer engagement in personal health records and health IT.

share resources through the TIGER Initiative Foundation website, which provides educational material regarding consumer empowerment and health IT.

encourage the TIGER Initiative community to utilize personal health records for their own personal well-being.

provide a consumer presence in the TIGER Initiative virtual learning environment.

Some of the TIGER Initiative's successes include:

The American Association of Colleges of Nursing board unanimously approved the revised Essentials of Baccalaureate Nursing Education for Professional Nurses, which recommends that graduates must have basic competence in technical skills, including the use of computers, as well as the application of patient-care technologies such as monitors, data gathering devices, and other technological supports for patient-care interventions.

Collaborative reports have been published covering the following topics: informatics competencies, standards and interoperability, national health IT policy, educational and faculty development, usability and clinical application design, leadership development, virtual demonstration center, and consumer empowerment and personal health records. (Each of the reports can be accessed and downloaded from the TIGER Initiative Foundation website at http://www.tigerinitiative.org.)

TIGER Initiative recommendations were included in the Institute of Medicine Future of Nursing report.

The TIGER Initiative made formal comments on the Centers for Medicare and Medicaid Services meaningful use criteria intentions and proposed rules to ensure they best meet the needs of clinicians and patients.

Transforming healthcare systems

As the TIGER Initiative evolves, it's committed to engaging diverse stakeholders to further its mission of advancing the integration of health informatics to transform practice, education, and consumer engagement. It's through these strategic directions that the TIGER Initiative will be able to advance nursing and other clinical professions to meet the challenge of transforming healthcare systems.

REFERENCE

1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011:172.

© 2013 by Lippincott Williams & Wilkins, Inc.

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TIGER Initiative: Advancing health IT : Nursing Management

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Department: Nursing Informatics Sally E. Schlak is the senior director of the TIGER Initiative Foundation and Michelle Troseth is chief professional practice officer at Elsevier's CPM Resource Center. The authors have disclosed that they have no financial relationships related to this article.

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Great illustration summarizing HI roles and goals

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC344585/

The article summarizes the definition of nursing informatics and how that term has evolved over the past three decades.

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J Am Med Inform Assoc. 2002 May-Jun; 9(3): 255-261.

A Critical Analysis and Revised Definition

Abstract

Despite the fact that nursing informatics is entering its third decade as a specialty within nursing, many definitions still exist to describe the field. This paper offers a rationale for a definition for nursing informatics and a critical analysis of past definitions. An organizing framework of technology-oriented, conceptual, and role-oriented definitions is used to critique these definitions. Subsequently, a revised definition is proposed. This evolutionary definition integrates critical concepts from past work and adds components that are currently missing-patients, information communication, information structures, and decision making. A separate role specification for informatics nurse specialists is provided.

Despite the fact that nursing informatics is entering its third decade as a specialty, many definitions still exist to describe the field.1, 2 In fact, authors have directed substantial efforts toward creating definitions for the specialty over the years.3-6 As a consequence, informatics practice and education have often proceeded without consensus about this fundamental element.

This paper offers a critical analysis of the evolution of major nursing informatics definitions. It also presents a revised definition of nursing informatics and a role specification for the informatics nurse specialist. Portions of an early draft of this paper were incorporated into the work by an American Nurses Association expert panel, which assumed the task of revising the scope of and standards of practice for nursing informatics in the United States.

The Need for a Definition of Nursing Informatics

"Medical informatics" is used as an overarching term both to describe any informatics efforts related to health care and also to describe a distinct specialty in the discipline of medicine. Consensus has not been reached about whether medical informatics, especially as the term is used in medicine, is the same discipline as what might more broadly be called health informatics.7, 8 Similarly, a lively debate in the literature underscores the disagreement about whether nursing informatics and medical informatics are separate disciplines.7

Regardless of the outcome of this debate external to nursing, nursing informatics is considered a distinct specialty within nursing. If for no other reason than that, a definition for nursing informatics is important for other nurses and for informatics nurse specialists, the label adopted by the ANA,9 because informatics nurse specialists need to be able to succinctly define their practice.

A definition is a fundamental element for shaping a specialty. A definition for nursing informatics guides role delineation for nurses interested in informatics and suggests directions for practice, education, training, and research. Also, a definition is one foundational element of national scope documents for the nursing informatics specialty. In particular, a national definition is used by funding agencies, such as the Division of Nursing in the Department of Health and Human Services and the National Institute for Nursing Research, to define projects and allocate monies to nursing informatics efforts.

Furthermore, a definition of nursing informatics may be useful to other disciplines as they define informatics practice within their own specialties. Finally, a definition for nursing informatics is needed to help others, within and outside nursing, understand the legitimacy of the practice and the general competencies of a nurse who specializes in informatics.

Definitions of Nursing Informatics

The authors reviewed work on definitions for nursing informatics. Other authors than those considered here have published important work related to facets of nursing informatics, such as defining requirements, designing nursing systems,10-12 and nurse- computer interaction.13 However, the focus of this analysis is on overarching definitions for the nursing informatics domain. A review of definitions of nursing informatics makes apparent three themes for analysis (revised from those suggested by Turley2)-information technology-oriented, conceptually oriented, and role-oriented definitions.

Information Technology-oriented Definitions

The use of information technologies in relation to those functions within the purview of nursing, and that are carried out by nurses when performing their duties. Therefore, any use of information technologies by nurses in relation to the care of their patients, the administration of health care facilities, or the educational preparation of individuals to practice the discipline is considered nursing informatics.

Saba and McCormick15 centered their first book on the notion of technology by outlining chapters related to "nursing information systems" and computer applications in the four areas of nursing. While the term "nursing informatics" did not appear in this book, the authors defined nursing information systems as systems that use computers to process nursing data into information to support all types of nursing activities or functions.

The use of technology and/or a computer system to collect, store, process, display, retrieve, and communicate timely data and information in and across health care facilities that administer nursing services and resources, manage the delivery of patient and nursing care, link research resources and findings to nursing practice, and apply educational resources to nursing education.5

All these authors make a salient point about the principal role that technology plays in informatics. For institutions installing clinical systems, technology can even seem to dominate all other issues during implementation. Some authors17 even argue that technology has been the primary driver of clinical processes, rather than the other way around.

The information technology-oriented view of nursing informatics may be critiqued for overstating the role of technology and underemphasizing the need for the informatics nurse specialist to support the cognitive interaction between the nurse, the nursing process, nursing data, patients and the technology. More important, emphasizing technology discounts the fact that informatics does not require the aid of a computer or other technology.8 Examples include reorganizing data presentation in a paper document to increase its information content, developing taxonomies to increase data sharing across sites, and conducting research related to the nursing minimum data set. These are essential informatics activities that are not centered on computer technology.

The technology-oriented definitions do not easily suggest the informatics functions a nurse might assume in a health care organization apart from the nurse's role in patient care. Specifically, informatics theories, principles, methods, and tools are not evident. These activities include, in part, needs analysis, requirements determination, structured system analysis, design, selection, implementation, and evaluation.

Although patients were mentioned by a few authors in technology-oriented definitions, the role of patients implicit in these early definitions was as more passive receivers of nursing care rather than as active partners involved in decisions related to their own care. Even this notion of the passive role of patients dropped from visibility in later nursing informatics definitions.

During the years since nursing informatics began, the role of patients in health care and in informatics has expanded greatly. It is common knowledge now that the Internet provides patients with an unparalleled amount of information about health, and the use of computers by patients in the home is more ordinary.19 Past definitions were constructed with patients as implicit rather than explicit players in health computing.

Conceptually Oriented Definitions

A shift from technology-focused definitions to more conceptually oriented definitions began during the mid 1980s. However, this approach did not gain acceptance until nearly 1990.

Schwirian. Schwirian20 moved away from technology and stressed the need for a "solid foundation of nursing informatics knowledge [that] should have focus, direction, and cumulative properties." She emphasized the need for informatics research to be "proactive and model-driven rather than reactive and problem-driven."

Schwirian cited Hannah's14 more technology-oriented definition of nursing informatics but produced a model that expanded thinking about the definition of nursing informatics beyond just a focus on technology. Her research model outlined a pyramid of users, nursing-related information, goals, and computers (hardware and software) interconnected with bidirectional arrows. Nursing informatics activity lies in the intersection of the other elements.

Meant as a stimulus for research in nursing informatics, the model could have been used to guide thinking about nursing informatics definition and practice as well. As was typical of earlier definitions, the roles of patients, nurse informatics specialists, and theories, concepts, methods, and tools are not made explicit. However, the model depicted the inter-relationships among interacting components and included new concepts of nursing-related information, goals, and context. Schwirian's emphasis on research was prescient, given the role research currently plays in informatics.

Graves and Corcoran. Graves and Corcoran4 provided the first widely cited definition downplaying the role of technology and incorporating a more conceptually oriented viewpoint:

A combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care.4

This definition broadened the horizon from technology and placed nursing informatics firmly within the practice of nursing. It also provided the first acknowledgment in nursing of an information-knowledge link, using concepts borrowed from Blois,21 and provided the foundation for Graves' work in knowledge building in the Sigma Theta Tau library.

Graves and Corcoran discussed the need to understand "how clinical nurses structure clinical problems and how they ask questions of the information system." These views drew researchers involved in the study of decision making under the rubric of nursing informatics. In addition, these views accented the need to consider the clinical decision-making process in the design of information systems. With an understanding of how captured data are used in decision making, designers can create systems that better meet the needs of nurses during their clinical decision-making processes. Graves and Corcoran's definition allowed a concentration on the purpose of technology rather than on the technology itself. Their transformation of the definition for nursing informatics changed the focus from technology to information concepts by expressly incorporating information science.

Graves and Corcoran's emphasis on nursing data, information, and knowledge was a novel change in direction in the late 1980s, and others immediately adopted the definition. The conceptual aspects of this definition of nursing informatics have been incorporated into many authors' works, including a review of the state of the science of nursing informatics by Henry22 and the National Institute of Nursing research priorities.23 Other authors supported this theme by stating that the main issues in nursing informatics are conceptual and information-related24-29 or by building on the initial work of Graves and Corcoran.4, 22 In fact, Henry's review of the state of the science in nursing informatics22 is organized using the concepts of nursing data, information, and knowledge.

One reason for the extensive acceptance of this new approach may have been that managing information (i.e., data, information, and knowledge processing) is at the core of nursing practice with or without technology. Therefore, the heart of the Graves and Corcoran definition4 resonated with practitioners, and an immediate connection was established between nursing practice and nursing informatics. The centrality of nursing practice in the Graves and Corcoran definition also supported the need for nursing informatics as a distinct specialty within health informatics. Although informatics nurse specialists use many of the same tools and processes as practitioners in other areas of informatics, the data, information, and knowledge have elements unique to nursing.

By changing their focus from this model in their second paper,4 Graves and Corcoran in effect narrowed the definition of nursing informatics, from the entire framework of nursing practice to the conceptual movement of data, information, and knowledge. This movement shifted the emphasis away from technology but also removed the context of nursing and de-emphasized the interrelationships among technology, nurse, and patients.

Turley. Turley2 analyzed previous nursing informatics definitions and then proposed a new nursing informatics model. Although he did not propose a new definition1 in this paper, by focusing on model development, he continued a conceptual approach to the definition of nursing informatics.

Turley's major contribution was the addition of cognitive science to a model comprising the original three sciences proposed by Graves and Corcoran.4 Cognitive science includes such topics as memory, problem solving, mental models, skill acquisition, language processing, and visual attention.2 These concepts can help informatics nurse specialists understand the decision-making and information processing done by nurses and, subsequently, assist in the creation appropriate tools to support nursing processes. Therefore, cognitive science is most helpful to informatics nurse specialists concentrating on informatics issues related to users, such as decision making and the construction of computer interfaces for nurses.

Although cognitive science is certainly a useful cognate for nursing informatics, the addition of a single science to a model may give prominence to one cognate and underplay the need for multiple cognates to support nursing informatics. For instance, if innovation diffusion is studied, the pertinence of cognitive science may fade in comparison with organizational politics. Turley's work represents a conceptual framework for the nursing informatics specialty and suggests that cognitive science should be added to the three core sciences included in definition of nursing informatics by Graves and Corcoran.4

Role-oriented Definitions

In the late 1980s, informatics nurse specialists were becoming more prevalent. Individuals were bootstrapping themselves into jobs related primarily to the insertion of computer technology into health care settings. The early information technology definitions suited these individuals, because the definitions emphasized the technology aspects of their job descriptions. Also, chief information officers at many institutions were most interested in persons who had a focus on technology.

As nursing informatics gained recognition as a nursing specialty, the Council of Computer Applications in Nursing, of the American Nurses Association (ANA),31 provided a new definition for the field. The ANA expanded the previous definitions by incorporating the role of the informatics nurse specialist into the earlier Graves and Corcoran definition4:

A specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, and research and to expand nursing knowledge. The purpose of nursing informatics is to analyze information requirements; design, implement and evaluate information systems and data structures that support nursing; and identify and apply computer technologies for nursing.31

The second sentence addresses concepts that represent the life cycle of information systems, more commonly called the "systems life cycle." This particular definition represents the first time concepts from an informatics method, the systems life cycle, appear in a definition.

In 1994, the ANA modified their definition in an effort to legitimize the specialty and guide efforts to create a certification examination:

Nursing informatics is the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research, and expansion of nursing knowledge. It supports the practice of all nursing specialties, in all sites and settings, whether at the basic or advanced level. The practice includes the development of applications, tools, processes, and structures that assist nurses with the management of data in taking care of patients or in supporting their practice of nursing.32

Although the 1994 ANA definition continued to provide information on the role of the informatics nurse specialist, the concepts from the systems life cycle were replaced with a more generic discussion of the role of the informatics nurse specialist.

Discussion

The early theoretic work of nursing informatics concentrated on three general themes-information technology, conceptual foundations, and the role of the informatics nurse specialist. The more technology-oriented definitions were a reflection of their era, and the definitions matched the task at hand. Schwirian's early work on a conceptual definition20 was largely ignored as practical issues rather than more theoretic work guided definitions.

As informatics became more integral to the practice of health care, formal programs of education were developed, and the specialty sought more conceptual definitions and models to underpin curricular development. Graves and Corcoran4 answered this need, and their thoughts became central to many authors' works. Their 1989 work4 narrowed the focus from the broader conceptualization of nursing informatics given in 198830 to the core concepts of managing and processing nursing data, information, and knowledge. Yet, it is the broader conceptualization outlined in the earlier Graves and Corcoran article that served as the foundation for nursing informatics curricular development at the University of Utah.33

As the specialty expanded in a complex practice arena, both technology-oriented and conceptual themes were deemed pertinent to nursing informatics. The ANA31, 32 offered a blend of these somewhat differing positions and added concepts related to the role of the informatics nurse specialist. These definitions first acknowledged the role of informatics nurse specialists and chose, from the suite of possible concepts, theories, and methods available to informatics nurse specialists, a single informatics method, the systems life cycle, as integral.

The evolution of definitions for the specialty of nursing informatics will undoubtedly continue into the near future at least. Endeavors directed toward refining the definition of nursing informatics should address the following issues.

First, even in this amalgam of definitions, the role of patients is underemphasized. As technology has become more widely available, patients are taking a more active role in their health care. Therefore, definitions of nursing informatics will need to consider this increased involvement in a refinement of a definition for the specialty.

Second, in the clinical setting, nurses are information integrators at the patient level. This close connection between nurse and patient in clinical settings has not been evident in past definitions, and the role of the nurse as information integrator has not been explicated. The role of nurses as they integrate data from and communicate data to other providers, such as other nurses, physicians and pharmacists, has not been highlighted. In a revised definition, nurses should be identified as information integrators among patients and other providers.

Third, other salient elements and their inter-relationships need to be addressed in a revised definition-support for decision making by nurses, technology, and context.

Fourth, the role of knowledge building through research is essential to include. This acknowledgment would begin to address the critical role of informatics research in current endeavors, such as evidenced-based practice, genomics, and neuroscience.

Finally, a new definition needs to consider pertinent theories, concepts, tools, and structures that are useful to the informatics nurse specialist-information structures (taxonomies and other meaningful organization of information), information technology, and the communication of information.

A Revised Definition of Nursing Informatics

From this analysis, it is clear that continued refinement of a definition of nursing informatics is required as the specialty of nursing informatics matures. However, a careful evolution of definitions is needed. There is danger in piecing together definitions from various fragments of work. For instance, if new definitions are created piecemeal and curricula are based on these pieces, resulting definitions and programs may end up being a collection of "hot topics."

Therefore, the previous analysis of the historical foundations of definitions of nursing informatics has been used to develop a revised definition. The revised definition for nursing informatics acknowledges the expanded role of patients in their own health care, the role of the informatics nurse specialist, the broad concepts of nursing and nursing informatics, and the inter-relationship of critical elements within nursing informatics.

The revised definition is as follows:

Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology.

Beyond the definition, the goal of nursing informatics is to improve the health of populations, communities, families, and individuals by optimizing information management and communication. This includes the use of information and technology in the direct provision of care, in establishing effective administrative systems, in managing and delivering educational experiences, in supporting lifelong learning, and in supporting nursing research.

A formal specification of the role of the informatics nurse specialist is also offered. A separation of role from definition may provide stability for the definition of nursing informatics, as the practice component is more susceptible to change in rapidly evolving technology and health care environments. The role of the informatics nurse specialist is:

To employ informatics theories, concepts, methods, and tools to analyze information and information system requirements; design, select, implement, and evaluate information systems, data structures, and decision-support mechanisms that support patients, nurses, and their human-computer interactions within health care contexts; and to facilitate the creation of new nursing knowledge.

Conclusion

This paper provides a critical analysis of definitions for nursing informatics. Three organizing elements form the structure for analysis-technology-oriented definitions, conceptually oriented definitions, and role-oriented definitions. Based on the critique of definitions, a revised definition for the specialty is proposed. This definition represents an evolutionary approach to defining nursing informatics, a logical step as the specialty matures.

Acknowledgments

The authors thank Patricia Flatley Brennan, PhD, RN, FAAN; Virginia K. Saba, PhD, RN, FAAN; and Rita Snyder-Halpern, PhD, RN, C, CNAA for their reviews of a preliminary draft of this manuscript. They also thank Judy Graves, PhD, RN, FAAN, who helped guide their theoretic thinking.

References

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5. Saba VK, McCormick KA. Nursing Informatics: Essentials of Computers for Nurses. New York: McGraw-Hill, 1996:221-63.

6. Scholes M, Barber B. Towards nursing informatics. In: Lindberg DAD, Kaihara S (eds). Medinfo 1980. Amsterdam, The Netherlands: North-Holland, 1980:70-3.

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14. Hannah KJ. Current trends in nursing in informatics: implications for curriculum planning. In: Hannah KJ, Guillemin EJ, Conklin DN (eds). Nursing Uses of Computers and Information Science. Proceedings of the IFIP/IMIA International Symposium on Nursing Uses of Computers and Information Science (Calgary, Alberta, Canada; May 1-3, 1985). Amsterdam, The Netherlands: Elsevier, 1985:181-7.

15. Saba VK, McCormick KA. Essentials of Computers for Nurses. Philadelphia, Pa.: Lippincott, 1986.

17. Hannah KJ, Ball MJ, Edwards MJA. Introduction to Nursing Informatics. New York: Springer-Verlag, 1994.

18. Dick RS, Steen EB, Detmer DS. The Computer-based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press, 1997.

21. Blois MS. Information and Medicine: The Nature of Medical Descriptions. Berkeley, Calif.: University of California Press, 1984.

23. National Center for Nursing Research. Nursing Informatics: Enhancing Patient Care. Bethesda, Md.: U.S. Department of Health and Human Services, 1993:3-9. NIH publication 93-2419.

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31. American Nurses Association Council on Computer Applications in Nursing. Report on the designation of nursing informatics as a nursing specialty. Congress of Nursing Practice unpublished report, 1992. Available from: American Nurses Association, Washington, DC.

32. American Nurses Association. The scope of practice for nursing informatics. Washington, DC: ANA, 1994. ANA publication NP-907.5M 5/94.

Articles from Journal of the American Medical Informatics Association : JAMIA are provided here courtesy of Oxford University Press

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The Evolution of Definitions for Nursing Informatics: A Critical Analysis and Revised Definition

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Despite the fact that nursing informatics is entering its third decade as a specialty within nursing, many definitions still exist to describe the field. This paper offers a rationale for a definition for nursing informatics and a critical analysis of ...