By Dan O’Connor, RN
As health information technology (IT) continues to evolve, leveraging more clinical information and adapting to changes in quality reporting, informatics is assuming a larger role in nursing practice. A new and exciting role outside traditional nursing, nursing informatics integrates data, information, and knowledge to support patient and provider decision-making through information structures, processes, and IT. The growing influence of nursing informatics, which mirrors the general ascension of healthcare data analytics across the country, merges technology into healthcare to optimize clinical care quality.
Transition in clinical documentation
Traditionally, clinical care was documented with pen and paper. The traditional model for using clinical data from a nursing perspective relied on chart reviews and spreadsheets, and the data was always historical in nature due to the process. While the transition to electronic health records has been underway for many years, only recently has data from multidisciplinary care teams, as well as historical data across the continuum of care, been readily available for integration.
When it began to take hold in the 1990s, electronic documentation was inconsistent. Information was often difficult for nursing leadership to obtain due to limitations in IT staffing and priorities that frequently focused on financial reporting or administrative initiatives, not on clinical care. The information that nursing managers needed took so long to acquire that it was outdated by the time they got it. As a result, nursing informatics gained little movement relative to other analytics in its early years.
To address this shortcoming, many organizations are shifting nursing analysts out of the IT department and creating new informatics departments within nursing practices. These new departments typically report directly to nursing rather than to IT, and focus on patient care and quality issues. A well-designed information system, supported by a nursing informatics team, can provide easier and faster information flow to keep pace with the increasingly complex care environment. The team can report on trends caused by seasonal issues such as influenza or global issues such as the Zika virus, and provide meaningful, real-time data that can directly impact the quality of care for provider organizations and communities.
Implications on patient care
As a result of advances in both the nursing environment and electronic documentation systems, nursing informatics can also directly impact the quality of patient care and outcomes. For example, the optimization of patient care documentation workflows and the advancement of clinical decision support provide immediate feedback to nurses and improve data used to monitor the quality of care. Electronic documentation has evolved to provide a direct link to the plan of care for patients, efficient communication among clinicians, and direct patient care processes that impact both patient safety and the quality of care.