Information systems that support effective clinical decision making
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November 2012 | Volume 19 | Number 7 NURSING MANAGEMENT 20 Feature Correspondence [email protected]Sharon Levy is telehealth nurse specialist, Scottish Centre for Telehealth and Telecare, and a member of the British Computer Society nursing specialist group Barbara Heyes is business development consultant, PRIMIS, University of Nottingham Date of acceptance September 29 2012 Peer review This article has been subject to double-blind review and checked using antiplagiarism software Author guidelines www.nursingmanagement.co.uk THE WORD ‘information’ is derived from the Latin ‘informare’, which means ‘to fashion, shape or create, to give form’. In other words, information is a concept given form through speech or writing to communicate an image or thought from one person to another. Effective communication is at the heart of professional nursing care as practitioners assess, capture and share information about patients’ health and care needs or concerns. Nurses also help patients to make sense of what is happening to them to empower them and assert their role as partners in decision making. The first article (Procter and Woodburn 2012) in this series notes that information systems that manage effective communication can be paperless or paper-based mechanisms that assemble, store, process and deliver relevant information to ‘users’. In health care, ‘users’ include patients, carers, health and care teams, administrators, managers and researchers. Information systems used in the health sector contain mainly records of human activity and enable us to refine how we think about patients and their needs, how care is provided and evaluated, and how nursing knowledge is created, captured, shared and applied. In the past 30 years the availability of digitised information has increased dramatically, largely due to the development of more sophisticated yet cheaper information and communication technologies (ICT) with large memory capacity and computation power. The cost of collating information has dropped significantly, and in healthcare services data collection has become integral to core patient or service user processing mechanisms. The digital revolution has enabled cheap and structured information to become a highly valued currency in the pursuit of the effective, efficient and transparent health care that people expect and demand. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care. Nurses deliver and manage care through continuous interaction with patients, families and other multidisciplinary team members. Nurses assess patients’ holistic care needs and develop care plans that can be shared with others when appropriate; they continually review patients’ recorded information and add observations and care outcomes. Nurses also monitor the instruments that record patients’ status or conditions, undertake tests and review the results of investigations performed by colleagues. Managing information and communication is a core principle of nursing practice (Casey and Wallis 2011), which must be perfected by all professionals who strive to improve patient care. To optimise patient outcomes, it is important to record and store relevant health data that can be accessed easily when needed to underpin clinical decision making, argue Sharon Levy and Barbara Heyes Information systems that support effective clinical decision making Abstract This article is the second in a series of four on the role of information and its management across health and social care. It describes the role of data in delivering nursing care and the importance of structured nursing content in electronic records to support modern services. The article gives examples of information systems that enable nurses to access data for clinical decision making, looks at the knowledge needs of future service users, and reflects on the support and training nurses need to operate in integrated health and care services. Keywords Information management, information systems
Information systems that support effective clinical decision making
