Nursing Informatics in Canada Notes
Nursing Informatics in Canada
Introduction
Registered nurses should advocate for and lead efforts in the collection, storage, retrieval, and use of nursing care data to generate information on nursing outcomes.
These data are essential for:
Expanding knowledge
Evaluating the quality and impact of nursing care
Promoting patient safety
Supporting integrated health human resources planning
Nursing's role in information management includes information necessary for:
Managing client care
Managing clinical operations
Client care and nursing management decision-making are increasingly underpinned by evidence.
Canadian nurses integrate information from various sources to inform practice and improve care quality and safety.
Access to practice outcomes provides evidence of nurses' essential contributions.
Substantial investments in ICT have been made across Canadian healthcare sectors.
Many care environments still require clinicians to use a combination of electronic and paper records.
Much work is needed to achieve a fully functional EHR in many settings.
Nursing documentation lacks standardization in data capture methodology and standardized clinical terminology for use in information systems.
Nursing documentation is often not yet part of the EHR.
Existing health information repositories do not include comprehensive information about the impacts of nursing practice.
Objectives
Describe key drivers advancing Canadian nurses’ use of information and communications technology.
Describe key organizations supporting the advancement of health and nursing information management in Canada.
Describe key nursing informatics initiatives currently underway in Canada.
Key words: Health information, Nursing data standards, Nursing outcomes, Information and knowledge management.
Key Factors Driving Nurses’ Use of Information and Communication Technology
The CNA believes that nurses and other stakeholders need information on nursing practice and its relationship to client outcomes.
A coordinated system to collect, store, and retrieve nursing data is essential for health human resource planning and to expand knowledge and research on quality nursing care.
Several professional nursing organizations are supporting nurses' involvement in health informatics:
CNA and its provincial and territorial affiliates
ACEN
CASN
CNIA
Other nursing informatics interest groups
Their collective efforts include:
Active dissemination of relevant information
Provision of opportunities for informatics education
Development of entry to practice competencies
Promotion and deployment of nursing data standards
Development of a national nursing report
Canada's healthcare system is unique because of its belief in health as a right rather than a privilege.
This philosophy is reflected in the principles of provincial and territorial health systems legislated through the Canada Health Act (Government of Canada, Minister of Justice, 1985):
Universality
Portability
Accessibility
Comprehensiveness
Public administration
Health is a provincial and territorial responsibility, conformity is by mutual consent, not legislation.
The publicly funded health system provides about 70% of healthcare, with the remainder paid out-of-pocket or by insurance.
Health system reviews have identified information systems as key enablers for health sector reform.
Kirby’s (2002) report emphasized improving health information management in Canada:
EHR solutions will enable the creation, analysis and dissemination of the best possible evidence from across Canada and around the world as a basis for more informed decisions by patients, citizens and caregivers; by health professionals and providers; and by health managers and policymakers. They will also help maximize the return on ICT investments through alignment, and drive the development of common standards and interoperability (p. 176).
Federal and jurisdictional investments in ICT were accelerated, making information management central to health service delivery.
An aging demographic and rising chronic disease costs have increased the use of ICT, such as telemedicine and telehomecare.
These cost-effective approaches remotely diagnose, manage, and monitor disease, supporting Canadians at home and nursing practice.
Nurses have an essential coordination role in telehomecare.
Care is increasingly deinstitutionalized with a greater emphasis on primary care and local delivery.
Changes in the scope of medical and nursing practice include a greater role for nurse practitioners.
The number of nurse practitioners has more than tripled over the last decade (Canadian Institute for Health Information, 2011).
Nursing remains central in evolving care delivery mechanisms, impacting the health of Canadians.
Increasing consumerism involves self-help, disease-specific, and special interest groups expecting involvement in their care and health information management.
The power differential between caregivers and patients is equilibrating through Internet access to information on disease management, treatment options, and provider performance.
Citizens use ICT to communicate with clinicians and exchange health information, transforming healthcare delivery.
These changes drive the identification of nurses' essential data needs.
Historically, healthcare organizations focused on using data for resource allocation, patient-specific costing, and health outcomes monitoring.
Nurses have used workload measurement systems without substantial impact on practice or care.
EHRs offer Canadian nursing an unprecedented opportunity to adopt standardized clinical terminology and create data repositories representing nursing practice.
Nurses' use of information systems in practice, administration, education, and research is pervasive.
Support for the Advancement of Effective Nursing Information Management
Key National Organizations
Canadian Institute for Health Information (CIHI)
Created in 1992, CIHI is an independent, pan-Canadian, not-for-profit organization.
Established jointly by federal, provincial, and territorial ministers of health.
Provides essential data and analysis on Canada’s health system and the health of Canadians.
Information is derived from hospitals, regional health authorities, medical practitioners, and governments.
CIHI focuses on:
Healthcare services
Health spending
Health human resources
Population health
CIHI has become a trusted source of quality, reliable, and timely aggregated health information.
Canada Health Infoway (Infoway)
The healthcare community realized limited information was available to caregivers for clinical decision-making.
In October 2000, the federal government committed initial funding to support the development and coordination of pan-Canadian health information systems for EHR.
This recognized ICT's potential to improve efficiency, cost-effectiveness, access, quality, and safety.
The Federal/Provincial/Territorial Advisory Committee on Health Infostructure (2001) prioritized EHR and telehealth development.
Incorporated in January 2001, Infoway is an independent, not-for-profit organization funded by the federal government.
Infoway jointly invests with provinces and territories to accelerate EHR projects.
Strategic investments support initiatives providing the foundation for an interoperable pan-Canadian EHR.
Most Canadian jurisdictions have basic infrastructure for an interoperable EHR, including:
Client registries
Provider registries
Drug information systems
Laboratory information systems
Diagnostic imaging information systems
Telehealth systems
Public health surveillance systems
Foundational systems provide the basis for provincial and territorial EHRs.
Considerable regional/local variation exists in adoption between organizations and clinical professions.
Key data elements for national and jurisdictional EHRs are yet to be confirmed.
Canadian nurses are working to ensure jurisdictional EHRs include patient-centered information and clinical outcomes data.
Substantial investment is directed to primary care EMR to support physician and nurse practitioner practice.
Through Infoway’s leadership, Canada became a charter member of IHTSDO in 2006.
Health data and technical standards are crucial for an interoperable EHR.
The emerging EHR will incorporate data related to patient assessment, interventions, outcomes, and provider patterns.
Nurses' contributions to care must be captured in the EHR.
Canadian Nurses Association (CNA)
The CNA established its eNursing Strategy in 2006, based on:
Nurses’ access
Competence
Participation in ICT use
These principles guide CNA's informatics activities.
CNA has led, participated in, and provided nursing perspectives on national health informatics initiatives.
EHR and data standards
NurseONE
C-HOBIC
NNQR
CASN’s Competency Development activities
Canada Health Infoway’s National Nursing Reference Group
Canadian Nursing Informatics Association (CNIA)
Efforts are needed to increase awareness among all nurses about the relevance of informatics.
Nurse leaders in practice and education need to embrace and advance the health informatics agenda.
Provincial nursing informatics interest groups emerged during the 1990s.
The CNIA was established in 2002 to engage nurses in all sectors and roles.
In 2004, the CNIA gained “Associate Group” status within the CNA.
This brings acknowledgment and recognition to CNIA, collaborating with CNA to review and influence national nursing policy and strategic planning related to informatics.
CNIA has a formal alliance with COACH, facilitating Canadian nurse nominees to IMIA SIG-NI.
IMIA SIG-NI engages with international nursing informatics colleagues.
Opportunities to leverage expertise are under discussion with colleagues in the United States, Europe, South America, and Australia.
CNIA maintains relationships with international colleagues launching NI groups.
International director roles on the CNIA Board enable mentoring and sharing lessons learned.
Key priorities for the CNIA:
Harnessing existing nursing informatics expertise
Addressing informatics competencies of all nurses
Extending the profession’s understanding of health informatics
Overall objectives:
Provide nursing leadership for the development of nursing and health informatics in Canada
Establish national networking opportunities for nurse informaticists
Facilitate informatics educational opportunities for all nurses in Canada
Engage in international nursing informatics initiatives
Act as a nursing advisory group in matters of nursing and health informatics
Expand awareness of nursing informatics to all nurses and the healthcare community
These objectives are being operationalized through biannual national conferences, a Web site, and a newly emerging informatics journal.
National Nursing Reference Group (NRG)
In 2009, the Canada Health Infoway Clinical Adoption group established a nursing reference group (NRG) in partnership with the CNA.
The NRG includes practicing nurses, national nursing associations, and other provincial nursing leaders and informatics experts.
The purpose of the NRG is to provide national nursing leadership, engagement, expertise, and input to inform Infoway’s nursing strategy and plans to accelerate nursing’s adoption and realization of the benefits of EHRs.
The objectives of the NRG are to:
Provide strategic-level advice and input on policies, priorities, and strategic plans aligned with Infoway’s Clinical Adoption business strategy and clinical engagement
Review and provide feedback on products, services, and projects under consideration, or being implemented where appropriate
Provide strategic input on the needs and engagement of nurses in practice, education, policy, administration, and research
Provide ongoing oversight and input into the established six key nursing strategic directions and tactical plans and associated working groups
Act as liaisons and promote a coordinated approach of activities and strategies within their organizations and across partners
In May 2009, six strategic goals were developed and preliminary action plans were established to accelerate nursing engagement and EHR adoption:
Identification of nursing key business and functional requirements
Development of a structure and strategy for collaboration
Development of an education strategy
Development of a communications strategy
Advancing and leveraging the C-HOBIC implementation
Advancing and leveraging the NurseONE portal
In March 2010, the NRG reviewed the previously identified nursing components of health information and validated their relevance for inclusion in EHRs.
Key National Initiatives Advancing Informatics in Nursing
NurseONE (www.nurseone.ca)
NurseOne is an innovative, Web-based portal created and maintained by the CNA.
It is a service for members to assist them in “keeping current, credible, competent, and connected” (CNA, 2014).
Through this service, nurses and nursing students can connect with each other through communities of practice and to credible, up-to-date electronic resources that support patient care and tools for lifelong learning.
e-books
e-learning courses
specialty libraries
databases
Webliographies
continuing education Webinars
Entry to Practice Informatics Competencies for Nurses
There is a need for nursing informatics competencies in basic nursing education programs.
Few nursing education programs offer informatics courses or content about ICT use and information management techniques.
Ideally, courses would introduce concepts and hands-on experience related to ICT use in practice.
In 2011, CASN secured funding from Canada Health Infoway to develop entry-to-practice nursing informatics competencies and a toolkit.
The competencies were created using a consensus-based, iterative process.
The published competency document includes an articulation of the expectation that students will have acquired basic computer literacy competencies prior to admission.
The informatics teaching toolkit provides strategies and methods to support faculty with the assimilation of informatics content into undergraduate curricula.
As nursing practice is increasingly enabled by technology, it is essential that basic nursing programs embrace nursing informatics.
Nursing Informatics Entry-to-Practice Competencies for Registered Nurses (2012)
Over-arching competency: Uses information and communication technologies to support information synthesis in accordance with professional and regulatory standards in the delivery of patient/client care.
Information and Knowledge Management Competency: Uses relevant information and knowledge to support the delivery of evidence-informed patient/client care.
Indicators:
Performs search and critical appraisal of online literature and resources to support clinical judgment, and evidence-informed decision-making.
Analyzes, interprets, and documents pertinent nursing data and patient data using standardized nursing and other clinical terminologies to support clinical decision-making and nursing practice improvements.
Assists patients and their families to access, review, and evaluate information they retrieve using ICTs and with leveraging ICTs to manage their health.
Describes the processes of data gathering, recording, and retrieval, in hybrid or homogenous health records, and identifies informational risks, gaps, and inconsistencies across the healthcare system.
Articulates the significance of information standards necessary for interoperable electronic health records across the healthcare system.
Articulates the importance of standardized nursing data to reflect nursing practice, to advance nursing knowledge, and to contribute to the value and understanding of nursing.
Critically evaluates data and information from a variety of sources to inform the delivery of nursing care.
Professional and Regulatory Accountability Competency: Uses ICTs in accordance with professional and regulatory standards and workplace policies.
Indicators:
Complies with legal and regulatory requirements, ethical standards, and organizational policies and procedures.
Advocates for the use of current and innovative information and communication technologies that support the delivery of safe, quality care.
Identifies and reports system process and functional issues according to organizational policies and procedures.
Maintains effective nursing practice and patient safety during any period of system unavailability by following organizational downtime and recovery policies and procedures.
Demonstrates that professional judgment must prevail in the presence of technologies designed to support clinical assessments, interventions, and evaluation.
Recognizes the importance of nurses’ involvement in the design, selection, implementation, and evaluation of applications and systems in healthcare.
Information and Communication Technologies Competency: Uses information and communication technologies in the delivery of patient/client care.
Indicators:
Identifies and demonstrates appropriate use of a variety of information and communication technologies to deliver safe nursing care to diverse populations in a variety of settings.
Uses decision support tools to assist clinical judgment and safe patient care.
Uses ICTs in a manner that supports the nurse–patient relationship.
Describes the various components of health information systems.
Describes the various types of electronic records used across the continuum of care and their clinical and administrative uses.
Describes the benefits of informatics to improve health systems, and the quality of inter-professional patient care.
Developing the Nursing Components of Health Information for Use in Canada
Nurses need to define the data elements required by nurses in Canada.
Canadian nurses are proactively mobilizing resources to ensure the development and implementation of a national health database that is congruent with the needs of nurses in all practice settings in Canada.
Health Information: Nursing Components
In 1997, a consensus was reached on five data elements:
Client status
Nursing interventions
Client outcome
Nursing intensity
Primary nurse identifier
Client status: a label for the set of indicators that reflect the phenomena for which nurses provide care, relative to the health status of clients (McGee, 1993).
Nursing interventions: purposeful and deliberate health-affecting interventions (direct and indirect) based on assessment of client status, which are designed to bring about results that benefit clients (AARN, 1994).
Client outcome: a “clients’ status at a defined point(s) following healthcare [–affecting] intervention” (Marek & Lang, 1993).
Nursing intensity: the amount and type of nursing resource used to provide care (O’Brien-Pallas & Giovannetti, 1993).
Primary nurse identifier: a single unique lifetime identification number for each individual nurse.
It's important to promote and develop the data elements and ensure they become integrated into an inter-professional, client-centred, pan-Canadian EHR.
With every new government agency or initiative, it is important to advocate for nursing data to be part of the inter-professional clinical data set.
In 2009, a nursing informatics think tank was hosted by the CNA and Infoway.
The first strategy area is the identification of nursing requirements for the pan-Canadian EHR, including both required functionality for nursing and the nursing core data.
In 2010, a renewed consensus was reached that nurses in Canada require data on client assessment, nursing interventions, client outcomes, nursing intensity, and a unique nurse identifier.
The forum also supported the position of the CNA, in advocating the International Classification of Nursing Practice® (ICNP®):
The adoption of a single clinical terminology that… facilitates communication across all health settings, spoken languages and geographic regions, that has the capacity to represent client health data and the clinical practice of all healthcare providers…For a clinical terminology to adequately represent the practice of registered nurses across all regions and settings it, must be developed in collaboration with the International Council of Nurses…. The International Classification of Nursing Practice (ICNP®) which is compliant with international standards in a manner consistent with other disciplines. (CNA, 2006a)
The Canadian Health Outcomes for Better Information and Care (C-HOBIC) Project
Infoway has invested to support capturing the “outcomes” dimension of patient care using nursing data.
In 2006, the CNA partnered with the Ministries of Health in three Canadian provinces to undertake the inclusion of 32 nursing-sensitive patient outcomes measures in four categories in EHRs.
Infoway provided funding for C-HOBIC, which supports the advancement and use of standardized patient assessments and related documentation.
Further, these assessments enable the provision of feedback to nurses about patient outcomes and the ability to compare outcomes over time.
C-HOBIC provides an EHR adoption lever, providing information of use to nursing practice.
The C-HOBIC project builds upon work originating in Ontario.
The 32 C-HOBIC measures were derived from evidence in the nursing literature and are in four categories:
Functional status
Symptoms
Safety
Readiness for discharge
The measures are constituted by 32 data elements that are being collected in four sectors of the healthcare system:
Acute care
Long-term care
Home care
Complex continuing care
Each of the measures has a concept definition and an associated valid and reliable measurement instrument.
As part of the C-HOBIC project, the concepts originally identified in Ontario were mapped to the International Classification of Nursing Practice®.
Experience with C-HOBIC to date indicates that these outcome measures can be collected using standardized tools across the healthcare system.
Moreover, the nurses using the measures are deriving value in addressing clinical care issues and quality improvement for their patients and clients.
Nurses must participate in the design, standards development, and pilot studies to ensure the capture of data that are essential to reflect nursing’s contribution to healthcare in Canada.
To ensure that data are available, reliable, valid, and comparable (i.e., data standards are established).
The CNA has endorsed the ICNP® for use in Canada.
It is also important to define the scope of the compiled data set to ensure that only those essential data elements are collected and to avoid proliferation of data, i.e., C-HOBIC data.
In addition, it is essential to promote the concept to ensure widespread use and educate the nurses to ensure the quality of the data that are collected.
National Nursing Quality Report-Canadian
Conceived in 2010 under the leadership of the ACEN and the CNA, the NNQR-C is a pilot project to determine the feasibility of using outcomes and productivity indicators to establish a monitoring system for health professionals, utilizing existing databases (HOBIC/C-HOBIC, Resident Assessment Instrument—interRAI, Discharge Abstract Database-DAD, Management Information Systems-MIS) (VanDeVelde-Coke et al., 2012)
The goals are to:
Implement a national nursing quality report (NNQR-C)
Evaluate the feasibility and costs associated with producing the indicators for healthcare organizations
Evaluate the potential of these indicators to impact organizational quality improvement and quality outcomes
The NNQR is envisioned as a minimum set of input, process, and outcome indicators that can be collected nationally across the continuum of care; can be readily available through dashboard applications in healthcare institutions; and can be used as benchmarks to influence policy directions for nursing to improve client outcomes in all care settings.
There are 15 indicators in the three categories of structure, process, and outcome.
There are 10 pilot sites from acute care, long-term care, and inpatient mental health, representing the provinces of Manitoba, Ontario, New Brunswick, and Nova Scotia.
The initiative has received a funding contribution from Canada Health Infoway as well as support from the sponsoring and participating organizations.
Influencing Nursing Informatics Globally: C-HOBIC, ICNP®, and SNOMED-CT
CNA formally endorsed the International Classification for Nursing Practice (ICNP®) in 2001 for use in Canada “as a foundational classification system for nursing practice in Canada” (CNA, 2001).
This endorsement was renewed in 2006 as CNA continued to promote accurate and timely capture of nursing data (CNA, 2006a).
The International Council of Nurses goals are increasing the visibility of nursing contributions in healthcare, standardization of nursing data to support inter-sectoral comparability and analysis, as well as supporting evidence-based practice were highly aligned to the nursing goals in Canada, and Canada has actively contributed to the progression of ICNP® through research.
As the C-HOBIC work progressed, extensive collaboration led to the development and approval of the ICNP® Catalogue, Nursing Outcomes Indicators.
Although Canada Health Infoway, in consultation with various stakeholder groups, adopted the SNOMED CT® as the terminology for the pan-Canadian electronic health record, ICNP® remained the preferred terminology for nursing.
In March 2010, ICN and the IHTSDO agreed to collaborate to harmonize terms in their two resources, further supporting interoperability.
Extensive efforts to cross-map and harmonize terms have improved both ICNP® and SNOMED CT®, resulting in numerous change requests for refinement of terms and new terms.
The Nursing Outcome Indicators catalogue has been used as a demonstration project for this purpose and has been cross-mapped to SNOMED CT.
On January 20, 2014, the ICN and the IHTSDO announced an equivalency table between the ICNP® concepts and SNOMED CT concepts.
The table contains ICNP® Diagnosis and Outcomes Statements that have semantic equivalencies with SNOMED CT concepts.
Conclusion
A continued priority for nursing in Canada is the deployment of solutions that support the capture and retrieval of essential nursing data.
Canadian nursing leaders are actively pursuing the vision to include these as core elements in a national health information database.
Progress has been made during the last decade, but nursing leaders must continue to respond to the challenge to further advance this agenda.
Early experience with the collection and use of the C-HOBIC measures demonstrates the great potential of a common clinical data set utilized across care settings.
Establishing a standardized set of nursing components for health information has the potential to provide nurses with the data required to transform nursing into a profession prepared to respond to the health needs of Canadians in the twenty-first century; however, the window of opportunity to have nursing data elements included in a national data set is narrowing.
We must continue our efforts to ensure that the vision of nursing components in our national health information system becomes a reality for nursing in Canada.