Table Of ContentComputers and Medicine
Helmuth F. Orthner, Series Editor
Springer
New York
Berlin
Heidelberg
Barcelona
Budapest
Hong Kong
London
Milan
Paris
Santa Clara
Singapore
Tokyo
Computers and Medicine
Use and Impact of Computers in Clinical Medicine
James G. Anderson and Stephen J. Jay (Editors)
Information Systems for Patient Care
Bruce I. Blum (Editor)
A Clinical Information System for Oncology
John P. Enterline, Raymond E. Lenhard, Jr., and Bruce I. Blum
(Editors)
The PACE System: An Expert Consulting System for Nurses
Steven Evans
Evaluation Methods in Medical Informatics
Charles P. Friedman and Jeremy C. Wyatt (Editors)
HELP: A Dynamic Hospital Information System
Gilad J. Kuperman, Reed M. Gardner, and T. Allan Pryor
Expert Critiquing Systems
Perry L. Miller
Selected Topics in Medical Artificial Intelligence
Perry L. Miller (Editor)
Implementing Health Care Information Systems
Helmuth F. Orthner and Bruce I. Blum (Editors)
Computer-Assisted Medical Decision Making, Volume 1
James A. Reggia and Stanley Tuhrim (Editors)
Computer-Assisted Medical Decision Making, Volume 2
James A. Reggia and Stanley Tuhrim (Editors)
Nursing and Computers: An Anthology, 1987-1996
Virginia K. Saba, Dorothy B. Pocklington, and Kenneth P. Miller
(Editors)
Nursing and Computers: An Anthology
Virginia K. Saba, Karen A. Rieder, and Dorothy B. Pocklington
(Editors)
(continued after index)
Virginia K. Saba
Dorothy B. Pocklington
Kenneth P. Miller
Editors
Nursing and COlllputers
An Anthology, 1987-1996
With 45 Illustrations
, Springer
Virginia K. Saba, EdD, RN, FAAN, Dorothy B. Pocklinglon, MSN, RN
FACMI 10061 Century Drive
2332 South Queen Street Ellicott City, MD 21042, USA
Arlington, V A 22202, USA
Kenneth P. Miller, PhD, RN, FAAN
Series Editor: 8014 Crabtree Place
Helmuth F. Orthner, PhD Gaithersbury, MD 20879, USA
Professor of Medical Infonnatics
University or Utah Health Sciences
Center
Salt Lake City, UT 84132, USA
Library of Congress Cataloging-in-Publication Data
Nursing and computers: an anthology, 1987-19961 [edited by] Virginia
K. Saba, Dorothy B. Pocklington, Kenneth P. Miller.
p. cm.--{Computers and medicine)
An anthology of selected classical articles and published papers on nursing informatics.
Includes bibliographical references.
ISBN -13:978-1-4612-7448-3 e·ISBN·I3: 978·1-4612·2182·]
001: 10.10071978-1-4612-2182-1
I. Nursing infonnatics. 2. Nursing-Data processing. I. Saba, Virginia K.
II. PocklinglOn, Dorothy B. III. Miller. Kenneth. 1948--. IV. Series: Computers and
medicine (New York, N.Y.)
[DNLM: I. Nursing-collected works. 2. Medical Infonnatics-rollected works.
WY 26.5 N9735 I997J
RT50.5.N863 1997
61O.73'0285--<1c21
97-12462
Printed on acid·free paper.
{;I 1998 Springer· Verlag New York. Inc.
Softcover reprint of the lIardcover 1 5t edition 1998
All rights reserved. This work may not be translated or copied in whole or in part without the
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analysis. Usc in connection with any form of information storage and retrieval. electronic
adaptation. computer software. or by similar or dissimilar methodology now known or hereaf
ter developed is forbidden.
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if the former are not especially identified. is not to be taken as a sign that such names. as
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ISBN-13:978-1-46l2-7448-3 Springer' Verlag New York Berlin Heidelberg SPIN 10552813
Series Preface
This monograph series intends to provide medical information scientists,
health care administrators, physicians, nurses, other health care providers,
and computer science professionals with successful examples and experi
ences of computer applications in health care settings. Through these com
puter applications, we attempt to show what is effective and efficient, and
hope to provide guidance on the acquisition or design of medical informa
tion systems so that costly mistakes can be avoided.
The health care provider organizations such as hospitals and clinics are
experiencing large demands for clinical information because of a transition
from a "fee-for-service" to a "capitation-based" health care economy. This
transition changes the way health care services are being paid for. Previ
ously, nearly all health care services were paid for by insurance companies
after the services were performed. Today, many procedures need to be pre
approved and many charges for clinical services must be justified to the
insurance plans. Ultimately, in a totally capitated system, the more patient
care services are provided per patient, the less profitable the health care
provider organization will be. Clearly, the financial risks have shifted from
the insurance carriers to the health care provider organizations. In order for
hospitals and clinics to assess these financial risks, management needs to
know what services are to be provided and how to reduce them without
impacting the quality of care. The balancing act of reducing costs but
maintaining health care quality and patient satisfaction requires accurate
information of the clinical services. The only way this information can be
collected cost-effectively is through the automation of the health care pro
cess itself. Unfortunately, current health information systems are not
comprehensive enough and their level of integration is low and primitive at
best. There are too many "islands" even within single health care provider
organizations.
With the rapid advance of digital communications technologies and the
acceptance of standard interfaces, these "islands" can be bridged to satisfy
most information needs of health care professionals and management. In
v
vi Series Preface
addition the migration of health information systems to web-based client!
server computer architectures allows us to re-engineer the user interface to
become more functional, pleasant, and also responsive. Eventually, we
hope, the clinical workstation will become the tool that health care pro
viders use interactively without intermediary data entry support.
Computer-based information systems provide more timely and legible
information than traditional paper-based systems. In addition, medical in
formation systems can monitor the process of health care and improve
quality of patient care by providing decision support for diagnosis or
therapy, clinical reminders for follow-up care, alerts about adverse drug
interactions, alternatives to questionable treatments, or warnings to devia
tions from clinical protocols, and more. The complexity of the health care
workplace requires a rich set of requirements for health information sys
tems. Further, the systems must respond quickly to user interactions and
queries in order to facilitate and not impede the work of health care pro
fessionals. Because of this and the requirement for a high level of securi
ty, these systems can be classified as very complex and, from a develop
er's perspective also as "risk" systems.
Information technology is advancing at an accelerated pace. Instead of
waiting for three years for a new generation of computer hardware, we are
now confronted with new computing hardware every 18 months. The forth
coming changes in the telecommunications industry will be revolutionary.
Within the next five years, and certainly before the end of this century, new
digital communications technologies, such as the Integrated Services Digi
tal Network (ISDN), Asynchronous Data Subscriber Loop (ADSL) tech
nologies, and very high speed local area networks using efficient cell
switching protocols (e.g., A TM), will not only change the architecture of
our information systems but also the way we work and manage health care
institutions.
The software industry constantly tries to provide tools and productive
development environments for the design, implementation, and mainte
nance of information systems. Still, the development of information sys
tems in medicine is an art, and the tools we use are often self-made and
crude. One area that needs desperate attention is the interaction of health
care providers with the computer. While the user interface needs improve
ment and the emerging graphical user-interfaces form the basis for such
improvements, the most important criterion is to provide relevant and
accurate information without drowning the physician in too much (irrel
evant) data.
To develop an effective clinical system requires an understanding of what
is to be done and how to do it, and an understanding of how to integrate
information systems into an operational health care environment. Such
knowledge is rarely found in anyone individual; all systems described in
this monograph series are the work of teams. The size of these teams is
usually small, and the composition is heterogeneous, i.e., health profession-
Series Preface vii
als, computer and communications scientists and engineers, statisticians,
epidemiologists; etc. The team members are usually dedicated to working
together over long periods of time, sometimes spanning decades.
Clinical information systems are dynamic systems; their functionality
constantly changing because of external pressures and administrative
changes in health care institutions. Good clinical information systems will
and should change the operational mode of patient care which, in turn,
should affect the functional requirements of the information systems. This
interplay requires that medical information systems be based on architec
tures that allow them to be adapted rapidly and with minimal expense. It
also requires a willingness by management of the health care institution to
adjust its operational procedures, and, most of all, to provide end-user
education in the use of information technology. While medical information
systems should be functionally integrated, these systems should also be
modular so that incremental upgrades, additions, and deletions of modules
can be done in order to match the pattern of capital resources and invest
ments available to an institution.
We are building medical information systems just as automobiles were
built early in this century, i.e., in an ad~hoc manner that disregarded even
existing standards. Although technical standards addressing computer and
communications technologies are necessary, they are insufficient. We still
need to develop conventions and agreements, and perhaps a few regula
tions that address the principal use of medical information in computer and
communication systems. Standardization allows the mass production of low
cost parts that can be used to build more complex structures. What
exactly are these parts in medical information systems? We need to identify,
classify, and describe them; publish their specifications; and, most impor
tantly, use them in real health care settings. We must be sure that these
parts are useful and cost effective even before we standardize them.
Clinical research, health services research, and medical education will
benefit greatly when controlled vocabularies are used more widely in the
practice of medicine. For practical reasons, the medical profession has
developed numerous classifications, nomenclatures, dictionary codes, and
thesauri (e.g., lCD, CPT, DSM, SNOMED, LOINC, COSTAR dictionary
codes, BAlK thesaurus terms, and MESH terms). The collection of these
terms represents a considerable amount of clinical activities, a large por
tion of the health care business, and access to our recorded knowledge.
These terms and codes form the glue that links the practice of medicine
with the business of medicine. They also link the practice of medicine with
the literature of medicine, with further links to medical research and edu
cation. Since information systems are more efficient in retrieving informa
tion when controlled vocabularies are used in large databases, the attempt
to unify and build bridges between these coding systems is a great exam
ple of unifying the field of medicine and health care by providing and
using medical informatics tools. The Unified Medical Language System
viii Series Preface
(UMLS) project of the National Library of Medicine, NIH, in Bethesda,
Maryland, is a prime example of such an effort.
The purpose of this series is to capture the experience of medical infor
matics teams that have successfully implemented and operated medical
information systems. We hope the individual books in this series will con
tribute to the evolution of medical, nursing, or health informatics as a rec
ognized professional discipline. We are at the threshold where there is not
just the need but already the momentum and interest in the health care and
computer science communities to identify and recognize the new disci
pline called Medical Informatics.
I would like to thank Springer-Verlag New York for the opportunity to
edit this series. Also, many thanks to the present and past departmental
chairmen who allowed me to spend time on this activity: William S.
Yamamoto, MD and Thomas E. Piemme, MD, of Department of Computer
Medicine at The George Washington University Medical Center in
Washington, DC, and Homer R. Warner, MD, PhD, and Reed M. Gardner,
PhD, of the Department of Medical Informatics at the University of Utah
Health Sciences Center in Salt Lake City, Utah. Last but not least I thank
all authors and editors of this monograph series for contributing to the
practice and theory of Medical Informatics.
Salt Lake City, Utah HELMUTH F. ORTHNER
Preface
This anthology consists of selected classical articles and published papers on
nursing informatics and is a compendium for maintaining and expanding
the knowledge base of computer technology in nursing. It serves as one
example of the transition of nursing knowledge of computer literacy as it
developed for the profession.
The first edition contained articles, published between 1981 and 1986,
from nursing journals and proceedings from computer conferences that
highlighted the entry of nursing informatics into the technological era.
However, this second volume represents landmark documents in the devel
opment and progress of nursing informatics, nursing information systems,
and other applications using computer technology.
This volume contains 87 articles from approximately 20 published
sources, such as proceedings, that have not been indexed in the major
computer-based health-related bibliographic retrieval systems. As a result,
these published papers are not compiled from a computer search of the
systems and therefore are not readily available or used to advance nursing
informatics and nursing knowledge.
The articles encompass a ten-year period from 1987 through 1996. The
majority of papers are primarily derived from proceedings, conferences,
and workshops, specifically:
• Nursing Informatics: NI' 88, NI' 91 & NI' 94 conferences:
(Proceedings of the Third, Fourth, & Fifth Conference on Nursing Use
of Computers and Information Science sponsored by International
Medical Informatics Association, Nursing Informatics (IMIA-NI
Special Interest Group)
• SCAMC: 1987-1990
(Proceedings of the Eleventh, Twelfth, Thirteenth, & Fourteenth Annual
Symposium on Computer Applications in Medical Care) sponsored by
the American Medical Informatics Association (AMIA).
• AMIA/SCAMC: 1991-1996
(Proceedings of the Fifteenth, Sixteenth, Seventeenth, & Eighteenth
ix
x Preface
Annual Symposium on Computer Applications in Medical Care) spon
sored by the American Medical Informatics Association (AMIA).
• Medical Informatics: MEDINFO' 89, MEDINFO' 92, & MEDINFO' 95
congresses:
(Proceedings of the Sixth, Seventh, & Eighth World Congress on Medical
Informatics sponsored by the International Medical Informatics Asso
ciation (IMIA).
• Medical Records Institute: 1988-1996
(Proceedings of the Annual Symposium entitled Toward an Electronic
Patient Record sponsored by the Medical Records Institute.
• Selected papers from other sources and conferences that focused on
Nursing Informatics such as Annual National Nursing Computer
Conference sponsored by Rutgers, the State University of New Jersey
College of Nursing Continuing Education Program.
Initially all nursing articles in the above publications were selected for
review by the three editors who were responsible for:
• Categorizing the articles into one of five topical areas: (1) general
informatics, (2) clinical practice, (3) nursing administration, (4) nursing
research, and (5) nursing education.
• Identifying the specific focus and topic for each article.
• Evaluating and prioritizing each article.
• Presenting, discussing, and reviewing each article in a group forum.
• Selecting and assigning each article to one editor for an introduction to
one of the five sections of the book.
The articles represent milestones as new nursing experts entered the
field of nursing informatics. This book will help to ensure that the effort
expended in the preparation of the articles is used to enhance and advance
nursing knowledge of nursing informatics.
This second volume is divided into five major sections: (1) General
Informatics, (2) Clinical Practice, (3) Nursing Administration, (4) Nursing
Research, and (5) Nursing Education; each with its own introduction that
highlights its selections, authors, and focus.
VIRGINIA K. SABA
DOROTHY B. POCKLINGTON
KENNETH P. MILLER
