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The notion of healthcare informatics is a relatively new development in the scope of the healthcare system. It “applies information science methods to analyze and understand health care information, to progress from raw data to knowledge, for improved problem solving, decision-making and care delivery”. It is an innovative approach that aims to improve health status both globally and individually, i.e., to enhance the health condition of individuals as well as of population groups. The aim of the paper is to identify theories and policies of healthcare informatics, to define crucial terms and notions in nursing language, standardized terminology and to illustrate meaningful use of clinical data records.
There are four major theories that support the healthcare informatics phenomenon, namely, systems theory, information theory, learning theory, and change theory. Each theoretical approach reveals particular aspects and potential of a given notion.
The systems theory is relevant when it proclaims the significance of the interoperability of all the parts of a particular system. The constructive interaction and mutually beneficial cooperation of every functional unit are crucial for the scope of activity of healthcare informatics. Furthermore, personnel is required not only to contribute to the overall professional performance course but also to interact and communicate efficiently as well as share experiences benefiting further improvement.
The information theory is also relevant in healthcare informatics analysis. The main concern within this theoretical framework is the level of adaptability of the message conveyed in the process of communication and interaction between nursing personnel. Nelson and Staggers (2014) dwell on diverse models which are considered to be the basis of the information theory. “The communication-information model provides an excellent framework for analyzing the effectiveness and efficiency of information transfer and communication”. Moreover, Nelson, Graves, and Blum have developed models that rely on such crucial constituent elements as data, information, and knowledge.
Learning theory aims to identify the key factors which have a prominent influence on the healthcare process and its basic stages. Since the learning processes are diverse, the influencing factors may vary to a certain extent. The significance of this type of theory in terms of healthcare informatics is crucial. There are numerous educational programs and policies that aim to develop professionals in the healthcare industry and healthcare informatics. The actual comprehension of the peculiarities of the learning process “is especially helpful in designing computer screens and developing computer-related procedures that are safe and effective for healthcare providers”. The learning process subdivides into the cognitive processes and constructionists.
Finally, the change theory deals with meaningful and perspective alterations both on individual and organizational levels. The change may be planned and spontaneous. In fact, Lewin's classification of the planned change is presented through three stages: unfreezing, moving and refreezing. The development of electronic documentation practices as well as unification and standardization of the nursing language and terminology shifts the paradigm of the traditional approach to the arising issues. Therefore, in healthcare informatics, change theory is particularly significant.
What approach is used for the development of the selected terminology?
The area of healthcare informatics is multidimensional even in the current stage of development. Therefore, it was subdivided into particular domains and categories, theories and policies which branch off and predetermine further evolution of the terminology. There are also several fields which tend to overlap with the currently discussed one in terms of focus and points of interest, namely, the biomedical informatics, bioinformatics, and clinical informatics. Actually, healthcare informatics’ major points of focus can be aligned with the keywords within its terminology. For example, such significant issues should be mentioned as “the design and implementation of electronic health records and decision support medical ontology construction information organization, storage and retrieval, artificial intelligence, text mining, data exchange, data standards and natural language processing in addition to security and privacy”. The above-presented terminology outlines the key concerns and predetermines the key objectives of the currently discussed scope of healthcare informatics. Since new directions and facets of the issue appear, the domain of terminology continues to develop. Therefore, the gradual and constructive approach is incorporated into the evolution of the theoretical framework of healthcare informatics.
The terminology presented above is standardized and approved by the American Society for Information Science and Technology. Moreover, healthcare informatics faces the challenge of an interdisciplinary field. Such a status guarantees broader recognition and more dynamic development of the nursing terminology. Furthermore, more and more relevant organizations tend to evaluate, analyze and approve this innovative branch of science.
The interdisciplinary nature of informatics is also reflected in recent statements of different organizations staring with the ACM (Association for Computing Machinery) to the American Nurses Association (ANA). Each of these organizations emphasizes the necessity of a broad-based approach to contemporary issues.
The standardized terminology can be captured in the nursing practice as long as it refers to the basic aspects of medical performance such as the design and implementation of electronic health records, data standards, natural language processing, security and privacy, and decision support. Hence, nursing may also incorporate the achievements of the healthcare informatics for the purpose of improvement.
What methods should be used to ensure appropriate implementation and terminology of consistent usage?
The course of implementation and subsequent usage of the terminology in a comparatively new field faces significant challenges and potential drawbacks. In order to ensure proper usage of the terminology, it is important to establish an appropriate level of comprehension of each term and notion. This will guarantee efficient and constructive incorporation of the terminology into practice. Moreover, it is necessary to provide a relative and sufficient theoretical background in order to guarantee consistency of theory implementation.
How does the nursing language support data collection for “Meaningful Use”? How would outcomes be measured or used in advanced nursing practice?
It is relevant to align the impact of nursing language with the level of efficiency of data collection. The meaningful use happens when “better healthcare does not result from the adoption of technology and electronic health records, but by increasing interoperability and informing clinical decisions at the point of care”. The interoperability may be achieved through workflow and diverse complex processes. The key to the efficiency of the aforementioned practice directly depends on the level of the actual involvement of all the responsible personnel. The nurses, as well as healthcare practitioners, are included in the list of participants of the meaningful use development. Their interaction and effective cooperation predetermine the course of communication. Therefore, the nursing language appears to be of a crucial significance. It makes the process of data collection for the purpose of meaningful use development and enhancement more constructive and efficient. The notion of nursing language is crucial for healthcare records and overall performance improvement. In fact, the descriptions may significantly vary as a direct result of differing perceptions and comprehensions of, for instance, bleeding strength. Therefore, errors, inconsistencies, and divergence may appear. They result from the inaccurate interpretation of the data, which is perceived in the wrong way. Nursing documentation reflects the actual empirical evidence, and, therefore, has to be as precise and objective as possible in order to represent the actual situation. According to Tubera (n.d.), “Although this type of documentation is flexible and requires no additional training, it is open to subjectivity and misinterpretations. The lack of consistency in nursing documentation has hindered communication and limited the comparison and analysis of nursing care.” Therefore, there is applicability in the establishment and development of a standardized nursing language. The constructive nursing language serves diverse functions. It clarifies and unifies the direct care data, guides the nursing process, and provides a background for efficient cooperation of the nursing personnel. The standardized nursing language can be defined as a commonly used language among the nursing staff that understood by every member of the personnel. This language is incorporated in practice in order to objectively describe the course of nursing.
The classic approach to the implementation of the nursing language to practice, aimed at enhancement of the meaningful use of the records, puts an emphasis on the following tendency: if a nurse is incapable to define and name a phenomenon, a symptom or a factor, it is apparent that this specialist will fail at controlling, researching, teaching others and exchanging the experience with other nurses. The commonly accepted and comprehended language contributes not only to the everyday communication and cooperation between the nurses and direct care but also is crucial for the implementation and use of electronic documentation. The nursing terminology is considered to be an essential tool for assessment of the clinical data, service provision, and outcomes’ development. One of the most practical and efficient standardized nursing terminologies is the Omaha System. This system is recognized by ANA and is addressed in the documents issued by the Alliance of Nursing Informatics (ANI). The Omaha System involves “characteristics described for meaningful use in that it is user-friendly, generates data that can be shared with patients and their families, and enables healthcare providers to analyze and exchange patient-centered coded data”. Moreover, the aforementioned system demonstrates congruence with the currently functioning standards and norms in the nursing care system. It is significant for the development within the public domain to cover the practical experience of nurses, the area of documentation and data management. The main features of the Omaha System include a diversity of the dimensions, hierarchical order, interdisciplinary nature, simplicity of use, and compatibility with computers that guarantees the development of electronic documentation and, at the same time, natural use of the standardized language in everyday practice.
What are the benefits and barriers to using this or any standardized nursing terminology? What makes this use beneficial or what prevents the use of terminology?
Nowadays the phenomenon of nursing language is a significant issue on the international scale. There are numerous challenges and barriers for implementation of the unified nursing terminology such as differences in languages, the healthcare system in general and nursing care in particular among different nations, dissonance in terms of innovations, alterations and new directions of professional performance. Nonetheless, the need for a standardized language is urgent, and several organizations on the national as well as international level initiated the establishment and development of the global standardized nursing language. Such initiatives will provide descriptions, in-depth insights and studies of the clinical data, and compare the communication of essential nursing activities in terms of diverse dimensions, namely, racial, national, and geographical ones. The benefits of standardized nursing terminology include:
- unified theoretical and empirical basis; excellent opportunities for experience exchange and consequent qualitative improvement of the nursing services;
- enhancement of communication between the nurses on different levels;
- development of transparent nursing interventions;
- efficient data collection process with a subsequent constructive evaluation of the ramifications of nursing care course;
- contribution to the improvement of adherence to standards and norms of the healthcare system.
Practically, incorporation of the standardized nursing language may be restricted by external and internal factors. For instance, it may depend on the differences in policies, contradictory aspects of professional performance as well as different proficiency levels and backgrounds of personnel.
Nevertheless, the phenomenon of standardized terminology has numerous benefits if the course of implementation is constructive, appropriate and consistent. The prerogatives and advantages include standardized professional performance that results in higher efficiency and an increase in interoperability, cooperation, and communication. Moreover, experience exchange and innovation enhancement also play a significant role in nursing practices.
Should there be a standard for the nursing language?
A standardized status for the nursing language is urgent and obligatory. It should be established, constantly developed and improved in order to foster the qualitative enhancement of nursing performance. Moreover, implemented standards are usually regarded as the basis for perspective expansion and globalization. Actually, the process of standardization of the nursing terminology is constructive for the international cooperation of the healthcare organizations and for the local nursing practices. Furthermore, it is a crucial contribution to electronic documentation and healthcare informatics.
Thus, healthcare informatics is a multidimensional and prospective area that aims at the provision of efficient comprehension of the clinical data, improvement of communication and interaction between the nursing personnel, and enhancement of the overall healthcare system. The field of healthcare informatics represents an innovative approach to the establishment and development of meaningful use of electronic documentation, which is based on comprehensive clinical data. There are four theories that support the phenomenon of healthcare informatics, namely, systems theory, information theory, learning theory, and change theory. Each theory is relevant in a given context of standardization of nursing language. The key concerns of the discussion are the notions of nursing language, standardized terminology and meaningful use of clinical data records. Nursing terminology is concluded to be an efficient and constructive development that contributes to the unification and standardization of the nursing practice. Furthermore, the initiative of standardization is expected to provide a prominent perspective on the further qualitative enhancement of the healthcare system on a global scale.
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