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referred to as nursing informaticians.Increasingly, however, there is a need forall nurses to integrate nursing informat-ics competencies into their practices.

While there is no standard definition forthe concept of nursing informatics, thefollowing definition was proposed in the1999 National Nursing InformaticsProject (NNIP) discussion paper: 1

Nursing Informatics (NI) is the application ofcomputer science and information science tonursing. NI promotes the generation, manage-ment and processing of relevant data in orderto use information and develop knowledge thatsupports nursing in all practice domains.

Applications of nursing informatics areillustrated in figure 1.

Building blocks of nursingcommunicationsThe foundation of nursing informatics isbased on the concepts of data, informa-tion and knowledge. Because informationand knowledge are essential for nurseswhen interpreting data and makingdecisions, it is important to know thedifference between these concepts.

I nformation is key to effective decision-making and integral to quality nursing practice. Much of

what nurses do involves information –from assessing the health care needs ofpatients, to developing care plans, tocommunicating patient information toother health professionals, to analyzingstaffing and budget reports – in fact,nurses work in an information-intensiveenvironment.

Advances in information technology(i.e., computers and software) over thelast 25 years have created significantopportunities for nurses to be aware ofcurrent information when making deci-sions. We have faster computers toprocess data, more sophisticated soft-ware to assist in the transformation ofdata into useful information, and power-ful communication technologies such asthe internet to enable the secure trans-mission of information among healthservice organizations and professionals.

Advances in information technologyhave accelerated efforts to implementinformation systems such as theelectronic health record. The electronichealth record (EHR) is a collection of allof an individual’s interactions withthe health care system that will beavailable electronically (subject toprivacy, confidentiality and securityguidelines and legislation) to healthcare professionals anywhere in thecountry. EHRs have the potential toenhance nurses’ decision-making

regarding the delivery of care by sup-plying access to health informationabout clients, allowing data-entry,and offering electronic access to sci-entific knowledge. In Canada, muchwork remains to be done to make theEHR a reality.

Advances in information technologyhave created new roles for nurses, and

emphasized the need for all nurses tobecome more knowledgeable abouthealth information concepts and thetechnology that is designed to manageand process information. Many nursesrecognize informatics, derived from theFrench term informatique, as an area ofnursing specialization. Nurses withexpertise in informatics are often

What is NursingInformatics and Whyis it so Important?

N u m b e r 11

FIGURE 1.

SAMPLE APPLICATIONS OF NURSING INFORMATICS

Clinical Practice• Recording of patient assessment data

in an electronic health record• Recording of workload and interven-

tions as a by-product of electroniccharting

Administration• Analysis of MIS reports generated from

a spreadsheet software application • Review of outcome indicators using a

decision-support software application • Recording of workload and interventions

as a by-product of electronic charting Education

• Distance learning/teaching via theinternet

• Recording of workload and interven-tions as a by-product of electroniccharting

Research• Evaluation of nurse-sensitive outcome

measures using a standard minimumdata set

• Use of knowledge bases via the internet • Recording of workload and interventions

as a by-product of electronic charting

S e p t e m b e r 2 0 01

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: prr@cna-nurses.ca

across disciplines and across the con-tinuum of health services need to bestructured and defined in a standard orcommon way – this means that notonly do we need standards for com-mon concepts but we also need stan-dards that are compatible across infor-mation systems used by differenthealth professions, across the continu-um of health service delivery, and with-in and across provinces and territories.

Notwithstanding all the challenges,there has been significant progressover the last decade in the develop-ment of health information stan-dards. Highlights of relevant workare provided here.

(a) Nursing TerminologyAt the international level, theInternational Council of Nurses (ICN)is leading the development of a univer-sal language for defining and describ-ing nursing practice – the InternationalClassification for Nursing Practice (ICNP®).The purpose of ICNP® is to provide atool for describing and documentingkey elements that represent clinicalnursing practice. ICNP® provides nurs-ing with a common framework thatfacilitates cross-mapping of existingnursing vocabularies and classifica-tions to enable comparison of nursingdata across organizations, health sec-tors, and countries. The alpha versionof ICNP® was released in 1996 forreview and feedback. A significantlyrevised beta version was released in1999 and has been translated intomore than 20 languages.

(b) Health Information: Nursing Components

In Canada, CNA’s HI: NC (HealthInformation: Nursing Components)Working Group has continued to buildon the work started in the early 1990sto develop a standardized minimumdata set for nursing. There is now anational consensus that critical nursingcare data elements include client status,nursing intervention and client outcome.

While nurses have reached a consen-sus on the kinds of data elementsrequired, they now must begin movingthese concepts to implementation by

Data are discrete observations that arenot interpreted, organized or struc-tured. Information is data that has beeninterpreted, organized or structured toprovide meaning to the data. Andknowledge is the synthesis of informa-tion to identify relationships thatprovide further insight to an issue orsubject area. When you think about it,these concepts are the building blocksof all nursing communications. Nursescollect data when assessing and moni-toring the health of clients and recordtheir observations in the client’s chart;they exchange service requests to, andreceive results from, the clinical labora-tory and radiology departments; theyreceive and review admission data anddischarge summaries; they review infor-mation on the results of clinical trials;they communicate client informationbetween service providers; they sum-marize, calculate and interpret work-load indices for their nursing unit formonitoring and management purposes;and they consult evidence-based clini-cal guidelines and protocols to guidetheir practice. As knowledge workers,nurses use sources such as these toinfluence decision-making.

Specific examples of data, informationand knowledge relevant to nursing areprovided below.

All three concepts can be stored incomputers and software programs canbe developed to assist in the interpre-tation of the data and the develop-ment of new nursing knowledge. Whilethe concepts of data, information andknowledge are different, the conceptsas a whole are typically referred togenerically as information.

Common language forcommon conceptsThe need for health information stan-dards has never been greater. TheInternational Organization forStandardization (ISO)2 defines stan-dards as: documented agreements containingtechnical specifications or other precise criteriato be used consistently as rules, guidelines, ordefinitions of characteristics to ensure thatmaterials, products, processes, and services arefit for their purpose. Today, there are manydifferent types of health informationstandards including technical stan-dards for computer hardware and soft-ware, data standards to enable thedevelopment of quality and compara-ble information, and informationexchange standards or protocols tofacilitate the sharing of information.

The development and implementa-tion of computer health information sys-tems or automated health information sys-tems requires some form of structuredvocabulary or terminology with com-mon definitions for common terms toenable the effective management andprocessing of data. This may seemsimple but is quite a challenge whenyou consider the complexity of issuesnurses have to deal with. In addition,nurses and other health professionalsoften use different terms and mea-surement instruments to describe thesame thing. For example, functionalstatus, decubitus ulcers, patient fallsand patient self-care are oftendefined and measured differently.

To complicate matters further, theadvent of multidisciplinary health pro-grams, regionalization and integratedhealth systems has increased the needfor integrated health information sys-tems that cut across traditional bound-aries. Concepts that are common

Data• Age• Number of home care visits• Blood pressure• Disease• Weight• Number of workload units of service

Information• Prevalence of patient falls by nursing unit,

by month – this year compared to last year• Prevalence of stage 1-4 decubitus

ulcers, by quarter

• % distribution of workload units of ser-vice and intervention by activity catego-ry, by nursing unit, by month

Knowledge• Effectiveness of hip pads in preventing

hip fractures • Decubitus ulcers treatment protocols• Relationship between different nurse-staff

mix configurations, nursing interventionsand client outcomes

• Care maps for specific health conditions

2

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: prr@cna-nurses.ca

Privacy, confidentiality andsecurity of health informationNurses have identified the protection ofpersonal health information as a criticalissue in the context of rapidly evolvinghealth information technologies.4 Thiscomes as no surprise since nurses,more than any other health profession,use, collect and record health informa-tion extensively in the delivery of care.Individuals and organizations responsi-ble for the development of systemsdesigned to collect, process, store, andshare health information have a respon-sibility to ensure that these systems aresecure in order to maintain the integrityand confidentiality of personal informa-tion. Without this respect for protectingthe privacy of an individual’s healthinformation, the public would lose con-fidence in the critical role that healthinformation plays in our health caresystem. At the same time, appropriateaccess to health information and datamay have important benefits forindividual Canadians and for thehealth system as a whole.5

With rapid advances in informationtechnology, nurses need basic knowl-edge of concepts relating to privacy,confidentiality and security of health infor-mation, especially if they are involvedin the development of health informa-tion systems. While related, theseconcepts are very different.

Privacy in relation to health informationis the right of an individual to deter-mine, when, how and to what extentthey will share information about them-selves with others. Confidentiality on theother hand, refers to the obligations ofone person to protect the personalinformation of another person. The pro-tection of the confidentiality of personalhealth information has always been afundamental principle of our healthcare system. The Code of Ethics for RegisteredNurses (CNA, 1997) states that nurses safe-guard the trust of clients that informationlearned in the context of a professional relation-ship is shared outside the health care team onlywith the client’s permission or as legallyrequired. Finally, security refers to the pro-cedures and technologies that are usedto restrict access to, and maintain theintegrity of health information.

ensuring that they are included withininformation systems. This involvesnurses assessing the health needs ofclients and collecting client-specificinterventions in a standardized way inorder to gain a better understandingof the impact of those interventionson client outcomes.

Many experts believe that nursingresource intensity3 and unique nurse identifier– a number or designation that couldenable data from several sources to belinked anonymously to an individual –are also key to representing nursingpractice within a larger system ofclient-centred health information. It isimportant for nurses to understandand be involved in discussions andactivities around these concepts.

The Canadian Institute for HealthInformation (CIHI) is currently workingwith nursing stakeholder groups todetermine the feasibility of imple-menting a unique identifier for nurses.CIHI completed a discussion paper onunique service provider identifiers thatis posted on its web site (www.cihi.ca).

Improved workload measurementsystems that come closer to measur-ing accurately the intensity of nurs-ing resources consumed by differenttypes of patients or health programsare critical for allocating resourcesappropriately. CIHI plans to establishan expert working group to reviewmany of the issues relating to nurs-ing workload measurement systemsand to make recommendationsregarding future developments andimplementation efforts.

(c) Classification Standard forHealth Interventions

CIHI completed the development ofa new Canadian Classification forHealth Interventions (CCI) that iscurrently being implemented in anumber of provinces. The CCI wasdeveloped to be consistent with con-cepts and terminology contained inthe ICNP®. The classification containsa comprehensive list of diagnostic,therapeutic, support and surgicalinterventions, allowing for the

standardized collection of healthinterventions, regardless of the serviceprovider or service setting.

(d) Classification Standard forHealth Conditions

To accompany the CCI, CIHI alsoenhanced the new version of theInternational Statistical Classificationof Diseases and Related HealthProblems, Tenth Revision for Canadianuse (ICD-10-CA). An example of codesin ICD-10-CA that are relevant to nurs-ing is presented below:

Nurses provided input to the develop-ment of both the CCI and ICD-10-CA.CIHI plans to maintain both classifica-tions on an ongoing basis to ensuretheir continued relevancy and utility tothe field. Nurses should play a key rolein ensuring that changes and enhance-ments to the classification are relevantto their information needs.

(e) Client Outcomes

With regard to the identification ofclient outcomes that are relevant to thework that nurses do, the OntarioNursing and Health Outcomes Projecthas done significant work in identifyingclient outcomes that are sensitive tonursing. The client outcomes that havebeen identified to date include: func-tional status, self-care, symptom con-trol (dyspnea, nausea, fatigue, pain),patient satisfaction with nursing care,adverse occurrences such as nosocomi-al infections, patient falls and decubi-tus ulcers. Future plans include devel-oping pilot projects in acute, long-termand community care.

ICD-10-CAL89 Decubitus Ulcers (DU)

L89.0 DU limited to erythema only (red-ness) without skin breakdown (stage1)

L89.1 DU limited to breakdown of skin(stage 2)

L89.2 DU with fat layer exposed (stage 3)

L89.3 DU with depth involving muscle(stage 4)

L89.4 DU with depth involving bone(stage 5)

L89.5 DU with joint space involvement(stage 6)

L89.6 DU with necrosis involving mus-cle/bone (stage X)

L89. 9 DU without mention of severity

3

CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-nurses.ca E-MAIL: prr@cna-nurses.ca

1 The NNIP was sponsored by the Canadian Association of University Schools of Nursing, the Registered NursesAssociation of British Columbia, the Academy of Canadian Executive Nurses, the Nursing Informatics Special InterestGroup of COACH, and CNA. One goal was to develop consensus on a definition of nursing informatics for Canada. Adiscussion paper was developed to elicit feedback from stakeholders in national nursing organizations, educational institu-tions, and nursing employers. Most respondents were in favour of the proposed definition.

2 The International Organization for Standardization (ISO): http://www.iso.ch/3

A combination of the amount of care and the skill level at which the care is provided. (Thomson, J. D. 1984. Themeasurement of nursing intensity. Health Care Financing Review, 6, 47-54). The intensity of the nursing response tothe conditions in patients that create the demand for nursing care. (O’Brien-Pallas, L., Irvince, D., Peereboom, E.,Murray, M. 1997. Measuring nursing workload: Understanding the variability. Nursing Economic$, 15[4], 171-182).

4In March 2000, a workshop (Vision 2020 Workshop on Information and Communications Technologies in Health Carefrom the Perspective of the Nursing Profession) was held to discuss information and communication technologies in thehealth sector from the nursing perspective. A report from the workshop is available at the Office of Health and theInformation Highway (OHIH) web site: http://www.hc-sc.gc/ohih-bsi/

5Canadian Nurses Association position statement: Privacy of personal health information. (2001).

6Based on similar figure in Background Document (1997). Working Group 3: Privacy, Confidentiality, Data Integrity, andSecurity of the Partnership for Health Informatics/Telematics. Canadian Institute for Health Information. Ottawa, ON.

Nursing Now is a series of shortpapers that explore issues andtrends in Canadian Nursing. This isthe 11th in the series.

Nursing Now is published by thePolicy, Regulation and ResearchDivision of the Canadian NursesAssociation (CNA).

Free copies are available to allCNA members. For additionalinformation and/or additionalcopies contact CNA Publications.

This publication is also available onCNA’s web site at www.cna-nurses.ca

ISSN 1206-3878

The establishment of various stan-dards related to privacy, confidentialityand security have evolved over theyears. Figure 2 presents the relation-ship between these concepts andrelevant standards.6

Federal/provincial/territorial laws andregulations uphold privacy and the pro-tection of personal information. Becausethese laws and regulations vary in termsof scope and comprehensiveness acrossthe country, federal/provincial/territorialofficials are currently working toward thedevelopment of a harmonized frame-work for the protection of health infor-mation in Canada.

Operational guidelines are requiredto ensure that an appropriate level ofconfidentiality of health informationis met. Within Canada, governmentsand various organizations and agen-cies have developed guidelines toassist in the implementation of leg-islative frameworks that are very

broad by nature. By implementingrecognized operational guidelines,health organizations can demon-strate to the public and others theircommitment to the protection of per-sonal information.

Examples of operational guidelinesin Canada that are relevant to thehealth system include: the recentlyupdated Guidelines for the Protection ofHealth Information produced by COACH– Canada’s Health InformaticsAssociation – and the CanadianStandards Association’s Model Code forthe Protection of Personal Information.

The COACH guidelines address practi-cal issues related to the protection ofhealth information and the mainte-nance of data integrity and informationsystem security and are used as a guideby health organizations across thecountry. The CSA model code is a vol-untary national standard for the protec-tion of personal information that wasapproved by the Standards Council ofCanada in 1996. The CSA standardaddresses two broad issues: the wayorganizations collect, use, disclose andprotect personal information; and theright of individuals to have access topersonal information about them-selves, and, if necessary, to have theinformation corrected. Ten interrelatedprinciples relating to accountability;identifying purpose; limitations ondata collection; limitations on use anddisclosure of information; consent;

accuracy; security safeguards; openness;individual access; and challenging com-pliance form the basis of the standard.

Finally, in implementing operationalguidelines, various procedures andsecurity systems are used, each basedon specific technical standards. Thereare just too many technical standardsrelated to information systems securityto discuss here; however, a few exam-ples that are relevant to nurses includetechnical standards relating to:

• the identification (e.g., passwords) andauthentication (e.g., digital signature) ofusers of health information;

• the provision of audit trails orrecords of access activity relating tohealth information; and

• the protection from unauthorizedaccess (e.g., firewall) to healthinformation.

Where can I get more information?Watch CNA’s web site! Articles focusingon electronic health record, classification ofdata and nursing resource intensity willbe published on the web site(www.cna-nurses.ca) starting in thefall 2001. Also listed are several otherresources on the topics of nursinginformatics and informatics in general.

Provincial/territorial nursing associationsand the Canadian Nursing InformaticsAssociation, listed on CNA’s web site,are excellent sources for up-to-dateinformation on nursing informatics.

PRIVACY Legislation e.g., Bill C-6

CONFIDENTIALITY Operational Guidelinese.g., CSA Model Code

SECURITY Technical Standardse.g., standards relating to digital signatures,passwords, firewalls

Figure 2. Matching Concepts and Standards –Privacy, Confidentiality, and Security

4