Information Systems
Technologies: Rewards and Risks

Registered nurses (RNs) are the primary information managers in clinical practice settings. RNs collect data, transform data to information, integrate information from multiple diverse sources, analyze information, make databased nursing care decisions, and communicate information .to others as appropriate (Zielstorff, Hudgings & Grobe, 1991). The skill employed and the activities undertaken by RNs information management make RNs the consummate knowledge workers of the 21st century. Along with cognitive nursing skills, RNs have employed information technologies of various complexities to meet the ever increasing demands for information and information management.

The purpose of this chapter is to inform RNs and other nursing personnel about current information technologies and potential risks associated with these technologies. The focus is on clinical nursing practice, since that is the domain of nursing in which the majority of RNs practice. First, current healthcare information technologies are described. Then, a discussion of the professional and legal risks associated with these technologies follows. Strategies that the individual RN might employ to reduce these risks are incorporated into the discussion as appropriate.

In this chapter, the concepts discussed are assumed to address the entire spectrum of nursing practice settings and the length of the healthcare continuum. Client is the term used to denote a recipient of RN services and may encompass an individual, a group of related or unrelated individuals, and communities (of any size).

This section begins with a discussion of the core source of client-specific health care: the client health record. A discussion of the two predominate information technologies which support this core source is provided. Then, the myriad supporting information technologies are described. Included in the discussions, as appropriate, are critical issues generated by these technologies.

The Client's Health Record

The most common information technology used in health care is the paper-based health record, which combines paper and writing instruments. The writing instruments may be manual (pen), mechanical (typewriter) or computerized (laboratory printouts). All written information about the client during an episode of health care is supposed to be captured in this document. (Images such as radiographs, sonograms, magnetic resonance imaging, etc. are stored separately from this record.) According to the Institute of Medicine, nearly every person in the United States who has had an encounter with the healthcare system has a paper-based health record (Dick & Steen, 1991 ). Most people have multiple health records kept by each practitioner they have visited. Even within one institution, a client may have more than one health record.

Although the paper-based health record has been in use for over a century, there has been growing criticism of its weaknesses and its inability to keep up with the rapidly increasing quantities of healthcare information generated and demanded by modem health care. The traditional organization of the paper record by sources and data chronology impedes the rapid retrieval and integration of data. Because all the client data are stored in a single document, only one person may have access to these data. Often, to counter this, different practitioners will remove the sections of the health record for which they have responsibility. This practice increases the difficulty in finding all of the pertinent information and integrating it into a comprehensive picture of the client's current status. As early as 1968, Dr. Lawrence Weed was identifying additional problems with the traditional health record such as illegibility, inaccuracy, duplication of data, gaps in information, and the misplacement or complete loss of information.

The electronic health record (EHR) is the solution most advocated for the problems of the paper-based health record and the information-intensive healthcare environment of today. The EHR is known by other terms such as computer-based patient record (CPR) and electronic medical record (EMR). Because it is computer-based, the EHR cannot be seen or touched. What is seen are displays on computer terminals and paper printouts ("hard copy"). An EHR is electronically maintained information about an individual's lifetime status and health care. Information in the EHR is characterized by content, representation, and time span (CPRI, 1996).

To provide the complete functionality that will result in the full range of possible benefits from the EHR, a supporting information system is essential. This may be known as an electronic health record system (EHRS), a clinical information system (CIS), a computer-based information system (CBIS), or some other variant. When the client-care information components of this information system are combined with administrative, financial, laboratory, and other information systems, the result is a healthcare information system (HIS). The EHRS supports the capture, storage, processing, communication, security, and presentation of electronic-based patient record information. It is the system that makes the EHR more than a static repository of data and information.

Hardware information technologies to support clinical nursing practice may be divided into mobile and stationm devices. Stationary devices include the ubiquitous portable computers (PC) and "dumb" terminals seen at nursing stations, the point-of-care, and other locations throughout a healthcare facility or office practice setting. Telephones and facsimile machines are another form of hardware information technology that supports the EHR and EHRS. Portable computers, often referred to as "workstations," are becoming the norm. These systems provide large screens, keyboards, and mouse/pointer devices for ease of use. Graphical, tabular, and text displays are available (Milholland, 1996).

Mobile technologies are becoming increasingly popular and available. They are intended for use in both institutional and home health settings, but the current emphasis is on their application for home health nurses. Regardless of where they are used, mobile devices add a level of freedom to the staff nurse who does not have to seek out a computer or paper chart for retrieving or recording patient information. Laptop/notebook computers are a common mobile information device, and they offer a large screen, a full keyboard and mouse/pointer capabilities but impose a weight and size burden. Hand-held devices most often are used for pen-based computing: a stylus is used to enter and retrieve information (there is no physical keyboard). Bar-code scanning is another feature of handheld devices which can be useful in tracking use of supplies and administration of medications (Milholland, 1996).

There are two main approaches to moving the information from the mobile computer to a more permanent system: wireless or phone-based. The wireless approach requires special transceivers mounted throughout the buildings where these devices are used. Usually, these transceivers automatically collect the data and information from the wireless device and transmit it to a receiving station which integrates the data into the enterprise's healthcare information system. Phone-based systems use a modem and a telephone line. (A modem is a special device which allows computers to use the telephone for communication.) This design is most often found in home health nursing, rather than in institutional settings. The nurse may phone in the information from the client's home or may wait until all home visits are completed before "downloading" the visit records from that day to the agency's computer. In the same vein, the nurse can have the health records for the next day's clients "uploaded" to the computer during the night so the information is available in the morning for review and planning (Milholland, 1996).

A recent innovation in wireless mobile information technology for institutional based healthcare practitioners is the portable phone. These cellular phones use a dedicated, transceiver-based system and replace personal beepers and overhead paging systems. Calls can be made or received from wherever the nurse is located.

Most everyone is familiar with Internet and the World Wide Web (WWW), that vast web of interconnected computers and software that enables people around the globe to communicate as if they were in the same room together. Healthcare practitioners, providers, and payers are viewing the Internet as a potentially powerful information technology for increasing access to healthcare, empowering consumers, educating practitioners, and transmitting healthcare information rapidly and cheaply. Some of the healthcare activities already occurring on the Internet are: transmitting requests for medications directly from the client's home to the prescriber's office, on-line hospital registration, development of "Home Pages" to provide clients with information about examination procedures, dissemination of clinical practice guidelines to practitioner's offices, and provision of continuing education programs (Milholland, 1996).

Regardless of the information technology used to create and support the EHR, there are numerous potential benefits (rewards), including reduction of administrative costs, enhancement of healthcare research, and improvement of client care. These benefits will be seen more and more as adoption of this information technology expands (Milholland & Heller, 1996).

Administrative benefits are accomplished via:

• reduced redundant data entry,
• electronic claims submission,
• improved risk management,
• reduced malpractice premiums,
• reduced record storage space,
• faster data retrieval time,
• improved provider productivity,
• provision of financial decision-support,
• closer connections between provider and client.

Healthcare research benefits from the use of EHRS, also. Because a EHR contains information from individual practitioner-client encounters, from entire treatment or illness episodes, and about a client's lifetime health status, there is a wealth of information available for study. Individual clients, groups of clients, individual practitioners, and groups of practitioners may be studied with greater ease because of the capacity and capabilities of EHRS.

The most important benefits of the EHR and EHRS for the client are:

• improved quality of care,
• improved access for practitioners to healthcare knowledge and decision support,
• elimination of duplicate tests and diagnostic activities,
• reduced delays in obtaining results of tests,
• enhanced clinical decision making,
• increased focus on wellness, health promotion, and disease prevention,
• linkage of protocols, client information, and healthcare knowledge,
• improved communication among practitioners,
• improved organization of client data, and timely data capture. (Milholland & Heller,1996).

Healthcare information technologies clearly have the potential for many rewards to practitioners and clients. However, along with the rewards of technologies come the risks. In this section, some of the potential risks of information technologies to RNs and their clients will be discussed. Possible strategies and/or actions to minimize these risks also will be presented. It is interesting to note that the major healthcare information publications do not address the professional or legal risks of these technologies. Problems with implementation and adoption of the systems are frequent topics, but not the risks. Yet every new technology inevitably has unexpected consequences and risks. More detailed analysis than what is in this chapter is needed. In the meantime, this chapter will help RNs to be prepared and pro-active.

For this section, risks are categorized as professional or legal. Professional risks are those that affect the profession of nursing and the individual RN's career. Legal risks concern the individual RN's license to practice and his/her vulnerability to legal action. It must be noted that the strategies to reduce the risks presented here may not be possible for an individual nurse to accomplish. However, if individual nurses work together as colleagues there is great power in numbers, persistence, and strong beliefs.

Professional Risks

The professional risks discussed in this section include: 1) the absence of nursing terms in electronic data sets, 2) the substitution of information technology for RNs, 3) documentation, 4) focusing on the technology instead of the client, 5) the potential for negative evaluation of nursing practice, and 6) physical safety of the nurse and the client. Space does not permit a comprehensive treatment of all potential professional risks, but these are key risks about which every RN needs to be aware.

Absence of nursing terms in electronic data sets.

The electronic health record and the systems which support it are focused on clinical client data. The data sets which are incorporated into the EHS are becoming increasingly multidisciplinary in nature'. Registered nurses must make sure that they are involved in the development of the data sets employed by the systems where they practice because without such involvement there is grave danger that the terms will not reflect nursing practice. The trend towards increasing multidisciplinary practice is a positive one. However, it often means that the work by nursing to identify and develop terminologies that encompass the nursing process is viewed as separatist or elitist. It is not. Nursing-focused information systems exist within the context of the total electronic health record system. The nursing profession supports multidisciplinary data collection and information management. However, it is absolutely essential that the data sets incorporate nursing terminology. Without the presence of this terminology, nurses will not be able to document the cognitive aspects of their practice (i.e., the intellectual processing of data into information and subsequent decision-making) and the outcomes of their work. Nurses and nursing practice will remain invisible to healthcare executives, to the public, and to policy makers.

The Nursing Minimum Data Set (Werley & Lang, 1988) has formed the basis for nursing data sets and nursing practice classification systems. The American Nurses Association has established a process for recognizing nursing classification systems that meet specific criteria for being useful to clinical practice. To date, there are four ANA-recognized nomenclatures: North American Nursing Diagnosis Association taxonomy of nursing diagnoses (NANDA, 1992); the Nursing Interventions Classification (McCloskey & Bulechek, 1992); the Omaha System (Martin & Sheet, 1992); and the Home Health Care Classification System (Saba, 1992). Knowledge of these nationally recognized nursing practice classification systems enables the practicing RN to advocate strongly for inclusion of nursing terms in the EHR. Other disciplines are not prevented from using these terms, nor is nursing prevented from using the terms of other disciplines. The power of the computer makes it very easy to establish common terms, add in terms that reflect a specific discipline, and conduct linkages to classification schemes behind the scenes. That is, the practitioner works only with the terms that are familiar and appropriate to his or her practice. Making sure the terms used are linked appropriately to nursing and other classification schemes is done by the computer, not the practitioner.

Substitution.

There is a growing concern among practicing RNs that the rapid adoption of healthcare information technologies will lead to the substitution of the technology for the human aspects of nursing. This concern is especially strong in the growing use of telecommunications technology for connection with geographically remote clients (telehealth). Many home healthcare services are using telecommunications to monitor the health status of their clients, thus decreasing the number of personal home visits by RNs. (It is interesting to note that this concern also is expressed by non-nurse healthcare practitioners.) The ANA and other nursing organizations strongly advocate that information technology is a tool to facilitate health care, not a substitute for in-person contact with the registered nurse. RNs participating in telehealth activities must be alert to and resist efforts to overuse the technology and under use the nurse. This issue is linked with the previously noted issue of the need for nursing terms to be included in EHRs. By having the data that demonstrate the improved outcomes when registered nurses regularly visit the client in the client's home setting, RNs are better prepared to counter the wholesale substitution of technology for professional practice.

1. A data set is a collection of terms or data elements organized to capture specific information.

Documentation.

For years, nurses, nurse executives, health policy analysts, health economists, advocates of the EHR, and many others have decried the vast percentage of professional nursing practice that is dedicated to documentation. Nursing documentation has been stigmatized as burdensome, excessive, and of little use or interest to others. It is not surprising that practicing RNs view documentation as a low priority item. As noted earlier, the adoption of an EHRS potentially will reduce much of the documentation burden. However, RNs must be careful that they do not give away the important aspects of nursing documentation in the rush to embrace EHRS benefits. As noted in the discussion of data sets, it is the documentation of nursing practice using nursing terms that will enable nursing to demonstrate its contributions to the quality of healthcare provided and to client and fiscal outcomes. As outcome-based measures of performance become increasingly adopted in healthcare, accurate and comprehensive documentation of nursing practice will be essential to maintaining and increasing nursing's influences within institutions and in health policy decisions. Thus, nurses need to resist the elimination of comprehensive nursing documentation for a short-term gain, but a long term loss. Documentation must be seen as a critical component of nursing practice, not an afterthought.

Focus on the technology and not the client.

Whenever new technologies are introduced, there is a very human tendency to divert one's focus to the technology. In nursing practice, this is a professional risk as it means less attention to the client with whom the nurse has a therapeutic relationship. That therapeutic relationship and the effectiveness of the nurse's practice may be diminished if the nurse cannot integrate the information technology into his/her practice in a seamless fashion. To counter this risk, each RN must be sensitive to its possibility, be on the alert for the diversion of focus, and work with the technology so that one is very comfortable with it. A high degree of comfort will lessen the amount of attention that must be given to the technology and will keep it as a tool to facilitate the practice of nursing.

Potential for negative evaluation of nursing practice.

Having practitioner and client data readily available for analyzing performance via client and fiscal outcomes means that nurses and nursing service units may be assessed as not performing up to expectations. This can be very scary to RNs, especially if such assessments are used in a punitive fashion. Enlightened organizations will use performance assessments to analyze what components of the healthcare organization are contributing to the performance problems and will work to resolve them (i.e., no blaming). This is the perspective that is supported by the federal government and by leaders in quality improvement methods. However, not all organizations are enlightened, and the fear felt by many RNs is valid. Nurses need to know what the performance expectations are for individual practitioners, nursing service units, and their organization as a whole. They need to demand this information for their own survival. Once this information is available, nurses might use it to do self-appraisals and to assess their nursing unit's performance and identify structure and process problems affecting that performance. Then, they can be proactive in seeking resolution of the problems and in developing strategies to meet performance expectations. Nurses also need to evaluate the performance expectations within the context of nursing's Code for Nurses (American Nurses Association, 1985), the Standards of Clinical Nursing Practice (ANA, 1992) and their scope of practice as delineated in their state nurse practice act. If the performance expectations are in conflict with these measures of nursing practice, nurses need to work with their organization to bring the performance expectations in line.

Physical safety.

Healthcare information technologies use many different devices in the collection and processing of data and information. Many of these devices are placed in institutional spaces which were not designed for computers or other electronic information devices. Often, the result is increasingly cluttered client care areas and awkward positioning of the devices for use by practitioners. Nurses may be forced into uncomfortable body positions for varying amounts of time. Back injuries from awkward placement of devices, neck strain from observing wall mounted display units, and hand and wrist problems from extended keyboard use are some of the potential physical risks. Further, the electronic nature of the devices poses potential safety risks to clients and to practitioners in the form of electric shocks and interference with implanted or external client care devices (e.g., pacemakers). Here, nurses need to be advocates for themselves and for their clients in seeking proper placement of electronic information devices and in obtaining information that the devices have been tested successfully for safety in a healthcare setting.

Legal Risks.

The legal risks discussed here are not a comprehensive discourse, but are significant issues about which RNs must be aware. These include documentation, over dependence on information technology, failure to use available information technology, and protection of privacy and confidentiality. As these technologies become more widely adopted, there will be increasing knowledge about the legal risks associated with them and pro-active preventive strategies for registered nurses.

Documentation.

Earlier, the information technology documentation-related risks to the nursing profession were discussed. There also are potential legal risks to the adoption of new documentation methods. Again, the comprehensiveness of nursing documentation and its relevance to the client's health are critical. If the terms that are incorporated into the EHR are not appropriate for describing what the nurse does and how the client responds, then there is an absence of evidence that what should have been done was done. This goes back to the old adage: "if it isn't written down, it wasn't done." With the trends to reduce the quantity of nursing documentation and the emergence of methods such as "charting by exception," nurses face increased risk of not having the evidence they might need to defend themselves in the event of legal actions. Complete and comprehensive written policies and procedures regarding new documentation models must be established before implementing a new charting method. One protection for RNs is to know and scrupulously follow those policies and procedures. Another is to inquire about the legal status of any new documentation model. Still another might be to point out the loss of client information that might explain variances in outcomes and costs if a new method is adopted.

Over-dependency on information technology.

Computers and the amazing things they can do lead many people to believe that information produced from a computer is always accurate and that computer-generated recommendations are far superior to human-generated decisions. This leads to over-dependency on the EHRS for clinical decision making. Information from the EHRS may not be critically analyzed or placed in the proper context. As a result, incorrect care decisions may be made. At a minimum, these decisions will delay the correct care and, at worse, they may directly cause harm to the client. In these instances, the nurse may be held liable for the harm. RNs must remember that computers are made and programmed by humans and that the data entry into the EHR is done primarily by humans. Computer error and human error are a constant possibility. No matter how sophisticated the information technology, the healthcare practitioner ultimately is responsible for final analysis of the information and for the clinical practice decisions made on the basis of the available information.

Failure to make use of information technology when available.

Just as there can be legal risk to over-dependence or faith in computer-based information technology, there can be similar risk when a practitioner fails to make use of available information technology. This is especially true when making practice decisions. For example, if nursing decision-support software is available, a nurse does not use it, and an incorrect diagnosis or intervention plan is made, there is potential liability. When there is access to scientific knowledge bases that would improve the accuracy of the practitioner's clinical decisions and the RN does not access those knowledge bases, there is greater legal risk in the event of an incorrect and harmful decision.

There is a fine balance between over-dependency on and non-use of available information technologies. As always, the RN is accountable for his or her decisions and actions and must make the determination of when to use the technology and when not to use it.

Privacy and confidentiality.

This is both a professional and a legal issue. RNs are ethically bound to protect the privacy and confidentiality of client information (ANA, 1985). However, the ubiquitous presence of information technology in health care increases the possibilities that client privacy and confidentiality may be breached and thus increases the legal risk to RNs. Computer systems actually are more secure than the paper health record, despite the attention given in the news media to computer system security breakdowns. Ibis does not mean they are impermeable, however; every institution which stores client information in a computer system has an obligation to use the best safeguards available to prevent unauthorized access from outside the institution. But inside a healthcare setting, it is the people who have to ensure that client and practitioner information is protected. This can be as simple as safeguarding assigned passwords (e.g., don't share it with anyone!). Each RN needs to sign off from the computer when done. This will prevent unauthorized access and the linkage of a practitioner's name with whatever an unauthorized user might do. Nurses must remember that the EHR is not the only information technology in use, as well. Telephones and facsimiles are used almost constantly to communicate client information. Thus, the person transmitting this information must make sure that the connection has been made with the right person or office and that transmitted materials are not left lying around. Non-professional staff need to be educated about the privacy and confidentiality aspects of using information devices.

Electronic health records (EHR) and electronic health record systems (EHRS) are increasingly present in nursing practice settings. These information technologies come in many shapes and sizes and may be stationary or mobile. Their adoption by nurses and other healthcare practitioners portend great changes in the nature, structures, and processes of healthcare delivery. Along with these changes comes the potential for great rewards that improve nursing practice, nursing administration, healthcare research, and client outcomes. Most of these rewards are still potential rewards, as the dissemination of EHRs and EHRS has moved slowly. Nonetheless, the rewards can be expected. Of course, there are concomitant professional and legal risks to the introduction of new technologies and practices. Nurses must be aware of these risks and be pro-active in devising solutions to minimize or prevent their occurrence. Cooperation will enable nurses to take advantage of their proportionally greater presence in healthcare settings, their positive status with the public, and their historic advocacy for the client to enact the solutions they devise.

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Martin, K., & Sheet, N. (1992). The Omaha System: Applications for community health nursing. Philadelphia: W.B. Saunders.

Milholland, D.K. (1996). Information technologies for clinical nursing practice. Emerging hardware/software support for staff nurses. The American Nurse, 96 (28), 2-3.

Milholland, D.K., & Heller, B.R. (1996). The computerbased patient record. In R. Mills, C. Romano, & B.R. Heller, (Eds.), Information management in nursing and health care (pp. 138 - 143). Springhouse, Pa.: Springhouse Corporation.

McCloskey, J., & Bulechek, G. (Eds.), (1992). Nursing Interventions Classification (NIC): Iowa Interventions Project. St. Louis: Mosby.

North American Nursing Diagnosis Association. (1992). NANDA Nursing diagnosis: Definition and classifications. St. Louis: Mosby.

Saba, V.K. (1992). The classification of home health care nursing diagnoses and interventions. Caring Magazine, 11(3), 50-57.

Weed, L.L. (1968). Medical records that guide and teach. New England Journal of Medicine, 12, 593-600, 652-657.

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D. Kathleen Milholland, Ph.D., RN, was previously a Senior Policy Fellow, Nursing Practice Health Policy, Department Of Nursing Practice, American Nurses Association. Washington, D. C. (This chapter is an original work. The opinions and ideas expressed herein are not necessarily those of the American Nurses Association.)

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Cochran, M. (May 1999). The real meaning of patient-nurse confidentiality. Critical Care Nursing Quarterly, 22(1), 42-51.

Habel, M. (January 31, 2000). Continuing education. Documenting patient care, part II: limit liability, trends and computer charting. Nurseweek, 13(3), 14-16.

Korn, K. (April 1999). Computer comments. Professional liability and risk management information on the internet. Journal of The American Academy of Nurse Practitioners, 11(4), 165=166.

Tidd, C, Reilly, B. (August 1999). Compliance, control & computers. Caring, 18 (8), 28-31-34-35.