Healthcare Informatics as Decision-Making Tools for Nurses

The nursing profession has at its disposal a variety of computer applications, and systems through which to collect, process, store, manage, and analyze data related to patient care and the administration of healthcare institutions. Ideally, these technical resources augment nurses' ability to deliver services to patients and make sound, informed judgments. Referred to collectively as "nursing informatics," they should be seen as an adjunct to an individual nurse's judgment and experience, not a replacement for them. The trend in information engineering in the healthcare setting is, and should be, toward integrative and interactive systems that optimize nurses' own knowledge base and enable nurses to draw upon the collective experience and wisdom of the profession.

One of the most basic of the information-processing tools available to nurses today is the word processor, a software application used to prepare printable documents. More efficient and flexible than old-fashioned manual typing, a word processing program enables a nurse to produce documents more quickly and to correct errors or make changes more easily. Through word processing, nurses can, with comparatively minimal effort, standardize patient records by creating and storing document templates. An example of a standardized, word-processed document is a patient intake form. In certain healthcare settings, for instance a hospital emergency room or a private doctor's office, new patients are generally asked a predetermined set of basic questions about their symptoms and medical history. A template for an intake form, with the standardized questions and blanks for patients' answers, may be created and stored in electronic form using a word processing form. When a nurse conducts patient intake, he or she can either input the patients' responses directly into the computer or print out a copy of the form in order to handwrite the patients' responses, which can be inputted into a computer database at a later time.

Another basic electronic information-processing tool is the spreadsheet, a computer-generated worksheet with multiple cells for data input. Spreadsheets are particularly helpful in the recording and manipulation of numerical data and are therefore ideal for administrative tasks related to nursing. An example would be a spreadsheet listing the costs for services provided to individual payments as well as payments for those services made by patients and their insurance companies.

Healthcare data can also be presented in graphical form, using charts, maps, and other visual aids. A graph can quickly convey the significance of a vast amount of data, often more forcefully than it could be expressed in either text or spreadsheet form. Graphical data is particularly useful in the areas of nursing education and research. An example would be a graph showing the incidence of certain characteristics among a particular patient population, for instance smoking and obesity among patients who suffer heart attacks.

Data from text documents, spreadsheets, and graphically displays can be incorporated into electronic medical records. An electronic medical record stores all the information regarding a patient's medical history, treatment, and care in digital format. An electronic medical record could include word processed information concerning a patient's medical history, diagnosis, and treatment; spreadsheet data regarding the patient's payment history; and graphical data related to a patient's medical condition, in the form of digitized x-rays or graphs of the patient's vital signs or blood test results over a period of time.

A documentation management system is an application that tracks and stores documents, both electronically created documents and digitized versions of paper documents. Documentation management systems greatly reduce the space and financial resources needed to maintain a "paper trail" of the documents that a healthcare provider or a healthcare institution must preserve in order to insure adequate patient care and administrative functioning. A document management system drastically reduces the time needed to store, file, and retrieve specific records.

Documents, spreadsheets, and electronic medical records can be stored in one or more databases, which collect and organize related electronic or digitized documents for quick and easy access and retrieval at a later time. There are a variety of database models: A flat database is the simplest type of database model to use and understand, consisting of a single file, generally in table format, with each row assigned to a particular patient record. In a flat database, there are no links between information contained in separate records and thus no means of creating or analyzing relations between the records. A hierarchical database, on the other hand, organizes records in an information "tree." A database of electronic medical records, for instance, would have an over-arching category entitled "Patients" with a record or file assigned to each individual patient. Information specific to each patient, for instance, past medical history, allergies to medication, test results, diagnoses, and treatment, would be filed in sub-categories under the main file or record assigned to the patient.

The healthcare industry is beginning to move away from flat and hierarchical databases toward object-oriented databases, which are capable of handling more complex information. An object-oriented database is distinguished by its ability to combine code (software system instructions for management of data) and data (information that is managed according to the system instructions) in a single "object." The use of objects allows the user to perform queries using the information in a database without having to formulate a whole new set of software instructions for each query.

Databases can be integrated into information systems, which not only store records and files but also perform tasks related to the processing and analysis of the data contained in the records and files. An information system automates information-processing functions routinely performed in the course of healthcare management.

Some information systems are "stand-alone;" that is, they are devoted to the management of information pertaining to a particular department, provider, or physical area of a healthcare institution. Stand-alone information systems have no interaction with systems used in other institutional departments. A common stand-alone information system is the specialty information system, devoted exclusively to the collection and analysis of data from one specialized hospital department, such as obstetrics, cardiology, or pharmacy. When providing effective patient care requires the consideration of data from multiple departments, a treating nurse may have to consult multiple information systems, which can be inefficient and time-consuming. Reliance on multiple stand-alone information systems can prove dangerous in a complex healthcare institution. A single patient may receive treatment from multiple departments during one hospital stay. An obstetrics nurse treating a pregnant woman may not provide the best care if he or she does not have access to the patient's latest blood test results which are contained only in the laboratory information system. Stand-alone systems may also result in nurses having an incomplete picture of a patient's medical history when that patient visits the hospital on repeated, separate occasions.

Thus, healthcare institutions have been turning more and more towards integrated information systems known as hospital information systems (Hannah 1998). An effective hospital information system is comprehensive, pooling data collected in all departments of the institution for easy retrieval, consultation, and analysis. Rather than employing independent stand-alone specialty information systems in each department of the institution, a hospital information system compiles data from numerous sub-systems. Hospitals and other healthcare institutions employ information systems to manage administrative and operational data. Sometimes these information systems are maintained separately, and sometimes they are integrated into the larger hospital information system. In such cases, the hospital information system has both clinical and administrative components.

An operations support system is a software application that monitors and controls functions such as inter- and intra-institutional telecommunications that are necessary to the physical functioning of the healthcare institution and to effective relationships and communications between various departments, physical areas, and nurses, other healthcare providers and other hospital or institutional staff. An administrative information system stores and manages all the data necessary for the smooth, successful day-to-day administration of a healthcare institution as a business venture, including patient and insurance payments, supply inventory and orders, and human resources data.

Arguably, the most important information systems used in the healthcare setting are expert systems and decision support systems. An expert system is a knowledge-based system that is, in essence, an effort to create an artificial intelligence to serve as a perfect virtual expert. A series of "rules" or premises are fed into the software program and the expert system reaches conclusions and decisions based on a logical analysis of those rules. Creating the rules for an expert system could involve, for instance, inputting into the system all the possible symptoms for various healthcare conditions. A nurse seeking a diagnosis in a difficult case could input all of a patient's symptoms into the expert system, which would analyze the inputted rules and propose one or more possible diagnoses that fit the symptoms reported by the patient.

As an entity endowed with artificial intelligence, an expert system in the nursing context is meant to act as a "super" expert nurse. However, a true expert system does not simply provide answers to queries; it should and must provide the human nurse using the system with an explanation of its rationale in reaching a particular conclusion. This explanation provides the nurse with an opportunity to evaluate the validity and usefulness of the expert system's conclusion.

An expert system relies heavily on the artificial intelligence programmed into the computer system itself to reach a conclusion. Even though a nurse has the option to reject or amend a conclusion proposed by an expert system, it is ultimately the expert system, not the nurse, who formulates the conclusion. However, nurses use decision support systems not to make decisionsbut rather to assist themselves and their patients in making the best decisions possible. A decision support system is of vital importance where a patient presents a complex or seemingly contradictory set of symptoms or where multiple health conditions make a choice of treatment plan particularly challenging. However, a decision support system is meant to be a resource for a nurse, not a replacement for his or her judgment. Ideally, a decision support system will provide a nurse with a number of alternative courses of action; the nurse will then assess those alternatives in the context of his or her own professional experience and clinical judgment. Fundamentally, the decision support system is a resource that draws upon the health care provider's own knowledge base. Much of what is programmed into a decision support system and many of the suggestions that it provides are already part of the nurse's own information arsenal. The decision support system is, after all, programmed by health care providers to draw upon the collective health care knowledge of the profession. However, while a nurse may know certain "facts," he or she may not always be able to recall those facts at the critical moment or may not realize the relevance of those facts to the situation at hand. Thus, the decision support system serves to "remind" the nurse of what he or she already knows.

Decision support systems for healthcare providers can be used in conjunction with decision aids for patients. In the case of a complex illness, such as cancer, where decisions about treatment are not clear-cut, decision aids help a patient understand his or her condition, and the possible alternative treatments. Examples of decision aids would include pamphlets, CDs, or interactive software designed for breast cancer patients. Such decision aids would inform the patient of the advantages and disadvantages of potential treatments for someone of her age and health status at her particular stage of the cancer. In offering such decision aids to patients, nurses recognize that, while their job entails drawing conclusions about a patient's condition and identifying viable alternative treatments, the final decision about how to proceed depends upon the patient's awareness of her options, her involvement in her own care, and ultimately her consent to a particular treatment. Nurses can only guide their patients' decisions, not make those decisions for their patients. Similarly, while expert systems and decision support systems are invaluable tools, nurses must ultimately reach their own conclusions, based on their own judgment and experience.

Expert and decision support systems represent the vanguard of informatics and computer technology in the nursing profession. These technologies aim to make the nurse "smarter" and more efficient by helping him or her use his or her own knowledge to its fullest extent. Ideally, all the technologies described in this paper enhance the nurse's abilities to think and act more efficiently. Word processing, spreadsheet programs and databases save time that can now be devoted to patient care and decision making. Integrated information systems enable the nurse to make comprehensive, well-informed decisions. While expert systems and decision support systems appear initially to take the onus of decision making off the nurse's shoulders, they cannot replace human wisdom. A software system cannot provide patient care. Nurses must resist the temptation to rely on information technology at the expense of their own judgment and experience. Rather, they must strive to use the available technologies to enrich their professional capabilities.