History of Nursing Informatics

 During the late 1960s through the 1970s, hospitals began developing computer-based information systems which initially focused on computerized physician order entry (CPOE) and results reporting; pharmacy, laboratory, and radiology reports; information for financial and managerial purposes; and physiologic monitoring systems in the intensive care units; and a few systems started to include care planning, decision support, and interdisciplinary problem lists. While the content contained in early hospital information systems frequently was not specific to nursing practice, a few systems did provide a few pioneer nurses with a foundation on which to base future nursing information systems (Blackmon et al., 1982; Collen, 1995; Ozbolt & Bakken, 2003; Romano, McCormick, & McNeely, 1982). Regardless of the focus, which remained primarily on medical practice, nurses often were involved in implementing health information technology (HIT) systems.

Interest in computers and nursing began to emerge in public health, home health, and education during the 1960s to 1970s. Automation in public health agencies began as a result of pressure to standardize data collection procedures and provide state-wide reports on the activities and health of the public (Parker, Ausman, & Ovedovitz, 1965). In the 1970s, conferences sponsored by the Division of Nursing (DN), Public Health Service (PHS), and the National League for Nursing (NLN) helped public health and home health nurses understand the importance of nursing data and their relationship to new Medicare and Medicaid legislation requirements passed in 1966. The conferences provided information on the usefulness of computers for capturing and aggregating home health and public health information. Additional government-sponsored conferences focused on educational uses of computers for nurses (Public Health Service, 1976). Simultaneously, hospitals and public health agencies embarked on investigating computers and nursing; the opportunity to improve education using computer technology commenced. Bitzer (1966) reported on one of the first uses of a computerized teaching system called PLATO, which was implemented to teach classes in offcampus sites as an alternative to traditional classroom education.

The early nursing networks, which were conceived at health informatics organizational meetings, helped to expand nursing awareness of computers and the impact HIT could have on practice. The state of technology initially limited opportunities for nurses to contribute to the HIT design, but as technology evolved toward the later part of the 1970s and as nurses provided workshops nationally, nurses gained confidence that they could use computers to improve practice. The national nursing organization’s federal agencies (Public Health Service, Army Nurse Corps) and several university schools of nursing provided educational conferences and workshops on the state-ofthe-art regarding computer technology and its influence on nursing. During this time, the Clinical Center at the National Institutes of Health implemented the Technicon Data System (TDS) system; one of the earliest clinical information systems (called Eclipsys & Allscripts) was the first system to include nursing practice protocols.

In addition to the use of computers, advancement was underway for other technologies and/or devices used by nurses. For example, the first point-of-care blood glucose monitor became available for use in the clinical setting in 1970 (Clarke & Foster, 2012). The devices became smaller and more widespread in the 1980s.

By the 1990s, large integrated healthcare delivery systems evolved, further creating the need for information across healthcare facilities within these large systems to standardize processes, control costs, and assure the quality of care (Shortliffe, Perreault, Wiederhold, & Pagan, 2003). Advances in relational databases, client-server architectures, and new programming methods created the opportunity for better application development at lower costs. Legislative activity in the mid-1990s paved the way for EHRs through the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (public-law 104-191), emphasizing standardized transactions, and privacy and security of patient-identifiable information (Gallagher, 2010). The complexity of technology, workflow analysis, and regulations shaped new roles for nursing.

In 1992, the ANA recognized nursing informatics as a new nursing specialty with a separate Scope of Nursing Informatics Practice Standards, and also established a specific credentialing examination for it (ANA, 2008). Numerous local, national, and international organizations provided a forum for networking and continuing education for nurses involved with informatics (Sackett & Erdley, 2002). The demand for NI expertise increased in the healthcare industry and other settings where nurses functioned, and the technology revolution continued to impact the nursing profession.

The need for computer-based nursing practice standards, data standards, nursing minimum data sets, and national databases emerged concurrently with the need for a unified nursing language, including nomenclatures, vocabularies, taxonomies, and classification schemes (Westra, Delaney, Konicek, & Keenan, 2008). Nurse administrators started to demand that the HITs include nursing care protocols and nurse educators continued to require the use of innovative technologies for all levels and types of nursing and patient education. Also, nurse researchers required knowledge representation, decision support, and expert systems based on standards that allowed for aggregated data (Bakken, 2006).

In 1997, the ANA developed the Nursing Information and Data Set Evaluation Center (NIDSEC) to evaluate and recognize nursing information systems (ANA, 1997). The purpose was to guide the development and selection of nursing systems that included standardized nursing terminologies integrated throughout the system whenever it was appropriate. There were four high-level standards: (a) inclusion of ANA-recognized terminologies; (b) linkages among concepts represented by the terminologies retained in a logical and reusable manner; (c) data included in a clinical data repository; and (d) general system characteristics. The Certification Commission for Health Information Technology (CCHIT) had similar criteria for the EHR certification, which was later adopted by the Office of the National Coordinator for Health Information Technology (ONC); however, nursing data was no longer included. ANA was ahead of its time in its thinking and development. The criteria are now under revision by the ANA to support nurses to advocate their requirements for the emerging HIT systems.

Technology rapidly changed in the 1990s, increasing its use within and across nursing units as well as across healthcare facilities. Computer hardware—PCs—continued to get smaller and computer notebooks were becoming affordable, increasing the types of computer technology available for nurses to use. Linking computers through networks both within hospitals and health systems as well as across systems facilitated the flow of patient information to provide better care. By 1995, the Internet began providing access to information and knowledge databases to be integrated into desktop computer systems. It revolutionized information technologies. The Internet moved into the mainstream social milieu with electronic mail (e-mail), file transfer protocol (FTP), Gopher, and Telnet, and World Wide Web (WWW) protocols greatly enhanced its usability and user-friendliness (Saba, 1996; Sparks, 1996). The Internet was used for high-performance computing and communication (HPCC) or the “information superhighway” and facilitated data exchange between computerized patient record systems across facilities and settings over time. The Internet led to improvements in networks, and a browser, WWW, allowed organizations to communicate more effectively and increased access to information that supported nursing practice. The WWW also became an integral part of the HIT systems and the means for nurses to browse the Internet and search worldwide resources (Nicoll, 1998; Saba, 1995).

During 2010, the ONC convened two national committees, (a) National Committee on Health Policy and National Committee on Health Standards, which outlined and designed to address the HITECH Act of 2009. The committees designed the “Meaningful Use” (MU) program which was to be implemented in three stages of legislation consisting of regulations which built onto each other with the ultimate goal of implementing a complete and interoperable EHR and/or HIT system in all U.S. hospitals. For each stage, regulations were proposed by the national committees, developed and reviewed by the public before they were finalized, and submitted to Centers for Medicare and Medicaid (CMS) and the healthcare facilities for implementation.

In 2011–2012, MU Stage 1 was initiated focusing primarily on the CPOE initiative for physicians. Hospitals that implemented this MU regulation successfully received federal funds for their HIT systems. In 2013–2015, MU Stage 2 was introduced focusing primarily on the implementation of quality indicators that required electronic data to be collected as an integral component in the HIT systems. The quality indicators would be used to guide hospitals in patient safety and if not implemented used as indicators subject to financial penalties. The proposed MU Stage 3 that focused on care quality outcome measures was not implemented but replaced by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA legislation created a new Medicare Quality Payment Program that prioritized the value of healthcare received by Medicare beneficiaries and revised Medicare’s reimbursement to eligible providers. The legislation consolidated components of the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) Incentive program into the Merit-Based Incentive Payment System (MIPS). The purpose of the MIPS program, initiated in 2017, was to establish Medicare payment to healthcare professional’s performance score based on a value-based healthcare model. As a result, the CMS began to focus reimbursement on a quality payment program that addressed quality outcome measures (MIPS, 2019). It is anticipated that this initiative will also minimize the payment burden on the clinicians by aggregating their patients’ health information from multiple providers into a single electronic application.

As of 2018, the CMS proposed policies to strengthen Interoperability. The ONC and CMS rebranded MU to Promoting Interoperability. It is anticipated that the initiative will make use of new technologies and for patients to aggregate their health information from multiple providers into a single electronic application. In 2019, the ONC continued to implement the latest legislation as well as Interoperability through summits, webinars, and public comment.

Nurses have always been involved with all phases of MU as well as all other legislation, from the implementation of systems to assuring usage and adaptation to the evolving health policy affecting the HIT and/or EHR systems. Thus, the field of nursing informatics (NI) continues to grow due to the MU regulations which continue to impact on every inpatient hospital in the country. To date, the majority of hospitals in the country has established HIT departments and has employed at least one nurse to serve as a NI expert to assist with the implementation of MU requirements. As the MU requirements changed they also impacted on the role of the NI experts in hospitals and ultimately on the roles of all nurses in the inpatient and outpatient facilities making NI an integral component of all professional nursing services. An example of nursing involvement is the implementation of the CCC System nursing terminologies for documenting nursing practice in the Hospital Corp of American (HCA) healthcare facilities (Saba & Whittenburg, 2015).