Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework

Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba

OBJECTIVE

To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba's contributions to nursing standardized nursing terminologies.

PROCESS

Experts led a day-and-a-half virtual update on nursing's sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health.

CONCLUSION

Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing's data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

Using Omaha System data to explore relationships between client outcomes, phenotypes, and targeted home intervention approaches: an exemplar examining practice effectiveness for older women with circulation problems

BACKGROUND

Improved health among older women remains elusive and may be linked to limited knowledge of and interventions targeted to population subgroups. Use of structured community nurse home visit data exploring relationships between client outcomes, phenotypes, and targeted intervention approaches may reveal new understandings of practice effectiveness.

MATERIALS AND METHODS

Omaha System data of 2363 women 65 years and older with circulation problems receiving at least 2 community nurse home visits were accessed. Previously identified phenotypes (Poor circulation; Irregular heart rate; and Limited symptoms), 7 intervention approaches (High-Surveillance; High-Teaching/Guidance/Counseling; Balanced-All; Balanced-Surveillance-Teaching/Guidance/Counseling; Low-Teaching/Guidance/Counseling-Balanced Other; Low-Surveillance-Mostly-Teaching/Guidance/Couseling-TreatmentProcedure-CaseManagement; and Mostly-TreatementProcedure+CaseManagement), and client knowledge, behavior, and status outcomes were used. Client-linked intervention approach counts, proportional use per phenotypes, and associations with client outcome scores were descriptively analyzed. Associations between intervention approach proportional use by phenotype and outcome scores were analyzed using parallel coordinate graph methodology for intervention approach effectiveness.

RESULTS

Percent use of intervention approach differed significantly by phenotype. The 2 most widely employed intervention approaches were characterized by either a high use of surveillance interventions or a balanced use of all intervention categories (surveillance, teaching/guidance/counseling, treatment-procedure, case-management). Mean outcome discharge and change scores significantly differed by intervention approach. Proportionally deployed intervention approach patterns by phenotype were associated with outcome small effects improvement.

DISCUSSIONS AND CONCLUSIONS

The Omaha System taxonomy supported the management and exploration of large multidimensional community nursing data of older women with circulation problems. This study offers a new way to examine intervention effectiveness using phenotype- and targeted intervention approach-informed structured data.

Comparison of nursing diagnostic accuracy when aided by Knowledge-Based Clinical Decision Support Systems with Clinical Diagnostic Validity and Bayesian Decision Models for psychiatric care plan formulation among nursing students: a quasi-experimental study

BACKGROUND

The most suitable and reliable inference engines for Clinical Decision Support Systems in nursing clinical practice have rarely been explored.

PURPOSE

This study examined the effect of Clinical Diagnostic Validity-based and Bayesian Decision-based Knowledge-Based Clinical Decision Support Systems on the diagnostic accuracy of nursing students during psychiatric or mental health nursing practicums.

METHODS

A single-blinded, non-equivalent control group pretest-posttest design was adopted. The participants were 607 nursing students. In the quasi-experimental design, two intervention groups used either a Knowledge-Based Clinical Decision Support System with the Clinical Diagnostic Validity or a Knowledge-Based Clinical Decision Support System with the Bayesian Decision inference engine to complete their practicum tasks. Additionally, a control group used the psychiatric care planning system without guidance indicators to support their decision-making. SPSS, version 20.0 (IBM, Armonk, NY, USA) was used for data analysis. chi-square (χ2) test and one-way analysis of variance (ANOVA) used for categorical and continuous variables, respectively. Analysis of covariance was done to examine the PPV and sensitivity in the three groups.

RESULTS

Results for the positive predictive value and sensitivity variables indicated that decision-making competency was highest in the Clinical Diagnostic Validity group, followed by the Bayesian and control groups. The Clinical Diagnostic Validity and Bayesian Decision groups significantly outperformed the control group in terms of scores on a 3Q model questionnaire and the modified Technology Acceptance Model 3. In terms of perceived usefulness and behavioral intention, the Clinical Diagnostic Validity group had significantly higher 3Q model and modified Technology Acceptance Model 3 scores than the Bayesian Decision group, which had significantly higher scores than the control group.

CONCLUSION

Knowledge-Based Clinical Decision Support Systems can be adopted to provide patient-oriented information and assist nursing student in the rapid management of patient information and formulation of patient-centered care plans.

Design and evaluation of a knowledge-based clinical decision support system for the psychiatric nursing process

BACKGROUND AND OBJECTIVES

The nursing assessment in the psychiatric department differ from those used in other departments considerably. We developed a psychiatric knowledge-based clinical decision support system (Psy-KBCDSS), which may aid nurses in solving patients' problems in the psychiatric department. In addition, we compared the sensitivity and specificity for the nursing diagnoses between the psychiatric nursing process system (Psy-NPS) and Psy-KBCDSS to determine that the Psy-KBCDSS can assist nurses in performing the nursing assessment and diagnosis.

METHODS

Visual Studio 2019 was adopted as the primary software development tool, and C# as the main development language. The concept of the nursing process was applied to develop the Psy-KBCDSS user interface. We developed a clinical diagnostic validity inference engine to calculate the frequencies of the nursing assessment items and nursing diagnoses in clinical tasks in the Psy-NPS for generating a knowledge-based database of the Psy-KBCDSS. The sensitivity and specificity for nursing diagnoses formulated by senior and junior nurses were used to determining the effectiveness of adopting Psy-NPS and Psy-KBCDSS.

RESULTS

This study include 22 nursing diagnoses commonly encountered in psychiatric wards. The top eight most common diagnoses in the Psy-NPS and Psy-KBCDSS were altered thought processes, ineffective coping, sensory and perceptual alterations, insomnia, risk for other-directed violence, anxiety, impaired social interaction, and risk for suicide. Compared with the Psy-NPS, the Psy-KBCDSS had significantly higher sensitivity for sensory and perceptual alterations, ineffective coping, and insomnia and significantly higher specificity for ineffective coping.

CONCLUSIONS

Considering its high sensitivity and specificity for various nursing diagnoses, the Psy-KBCDSS, as an empirical patient-oriented nursing clinical decision-making support system, can assist nurses in clinical nursing tasks including nursing process-based patient assessment and nursing diagnosis.

A Knowledge Graph to Understand Nursing Big Data: Case Example for Guidance

PURPOSE

To provide a summary of research on ontology development in the Centre of eIntegrated Care at Dublin City University, Ireland.

DESIGN

Design science methods using Open Innovation 2.0.

METHODS

This was a co-participatory study focusing on adoption of health informatics standards and translation of nursing knowledge to advance nursing theory through a nursing knowledge graph (NKG). In this article we outline groundwork research conducted through a focused analysis to advance structural interoperability and to inform integrated care in Ireland. We provide illustrated details on a simple example of initial research available through open access.

FINDINGS

For this phase of development, the initial completed research is presented and discussed.

CONCLUSIONS

We conclude by promoting the use of knowledge graphs for visualization of diverse knowledge translation, which can be used as a primer to gain valuable insights into nursing interventions to inform big data science in the future.

CLINICAL RELEVANCE

In line with stated global policy, the uptake and use of health informatics standards in design science within the profession of nursing is a priority. Nursing leaders should initially focus on health informatics standards relating to structural interoperability to inform development of NKGs. This will provide a robust foundation to gain valuable insights into articulating the nursing contribution in relation to the design of digital health and progress the nursing contribution to targeted data sources for the advancement of United Nations Sustainable Development Goal Three.

Development of a Theory of Wisdom-in-Action for Clinical Nursing

Nurses published dialogues on wisdom; yet, a conceptual model is unavailable. We present the development process for a theory of wisdom-in-action for clinical nursing developed in 3 phases: (1) a deductively derived model using derivation and synthesis; (2) inductively, a constructivist grounded theory captured the experience of wisdom in nursing practice; and (3) the 2 theories were synthesized into a nascent theory. The theory describes 2 antecedent dimensions, person-related and setting-related factors, and 2 types of wisdom, general and personal. The theory provides a framework for translating wisdom in nursing practice, depicting both the science and art of nursing.

Beyond the hype of big data and artificial intelligence: building foundations for knowledge and wisdom

Big data, coupled with the use of advanced analytical approaches, such as artificial intelligence (AI), have the potential to improve medical outcomes and population health. Data that are routinely generated from, for example, electronic medical records and smart devices have become progressively easier and cheaper to collect, process, and analyze. In recent decades, this has prompted a substantial increase in biomedical research efforts outside traditional clinical trial settings. Despite the apparent enthusiasm of researchers, funders, and the media, evidence is scarce for successful implementation of products, algorithms, and services arising that make a real difference to clinical care. This article collection provides concrete examples of how "big data" can be used to advance healthcare and discusses some of the limitations and challenges encountered with this type of research. It primarily focuses on real-world data, such as electronic medical records and genomic medicine, considers new developments in AI and digital health, and discusses ethical considerations and issues related to data sharing. Overall, we remain positive that big data studies and associated new technologies will continue to guide novel, exciting research that will ultimately improve healthcare and medicine-but we are also realistic that concerns remain about privacy, equity, security, and benefit to all.

Clinical Information Needs: A Concept Analysis

Health care organizations have invested resources to implement and upgrade information systems capable of collecting large quantities of data. Recent technology developments have created a renewed interest in studying clinician information needs. However, a common definition and analysis of the concept clinical information needs have not been provided. Walker and Avant's method was used to perform a concept analysis. Following a review of relevant literature, a clinical information need was defined as a conscious expression, which can be verbal or nonverbal, of a desire for knowledge to answer clinical questions in the course of decision making to deliver patient care.

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test

BACKGROUND

Adolescents with type 1 diabetes mellitus have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents' thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision-making process.

OBJECTIVE

The objective of our study was to codesign a clinic intervention using shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board.

METHODS

The patient and parent advisory board consisted of 6 adolescents (teens) between the ages 12 and 18 years with type 1 diabetes mellitus and their parents recruited through our institution's Pediatric Diabetes Program. Teens and parents provided informed consent and participated in 1 or both of 2 patient and parent advisory board sessions, lasting 3 to 4 hours each. Session 1 topics were (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was used. We analyzed audio recordings, notes, and other materials to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These data were visually coded into similar themes. We used the information to develop a prototype for a diabetes management plan tool that we pilot tested during session 2.

RESULTS

Session 1 identified 6 principal patient-centered quality-of-life measurement domains: stress, fear and worry, mealtime struggles, assumptions and judgments, feeling abnormal, and conflict. We determined 2 objectives to be principally important for a diabetes management plan intervention: (1) focusing the intervention on diabetes distress and conflict resolution strategies, and (2) working toward a verbalized common goal. In session 2, we created the diabetes management plan tool according to these findings and will use it in a clinical trial with the aim of assisting with patient-centered goal setting.

CONCLUSIONS

Patients with type 1 diabetes mellitus can be effectively engaged and involved in patient-centered research design. Teens with type 1 diabetes mellitus prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with type 1 diabetes mellitus.

An ontology of and roadmap for mHealth research

PURPOSE

Mobile health or mHealth research has been growing exponentially in recent years. However, the research on mHealth has been ad-hoc and selective without a clear definition of the mHealth domain. Without a roadmap for research we may not realize the full potential of mHealth. In this paper, we present an ontological framework to define the mHealth domain and illuminate a roadmap.

METHODS

We present an ontology of mHealth. The ontology is developed by systematically deconstructing the domain into its primary dimensions and elements. We map the extent research on mHealth in 2014 onto the ontology and highlight the bright, light, and blind/blank spots which represent the emphasis of mHealth research.

FINDINGS

The emphases of mHealth research in 2014 are very uneven. There are a few bright spots and many light spots. The research predominantly focuses on individuals' use of mobile devices and applications to capture or obtain health-related data mostly to improve quality of care through mobile intervention.

CONCLUSIONS

We argue that the emphases can be balanced in the roadmap for mHealth research. The ontological mapping plays an integral role in developing and maintaining the roadmap which can be updated periodically to continuously assess and guide mHealth research.

Powering Big Data for Nursing Through Partnership

The Big Data Principles Workgroup (Workgroup) was established with support of the Healthcare Information and Management Systems Society. Building on the Triple Aim challenge, the Workgroup sought to identify Big Data principles, barriers, and challenges to nurse-sensitive data inclusion into Big Data sets. The product of this pioneering partnership Workgroup was the "Guiding Principles for Big Data in Nursing-Using Big Data to Improve the Quality of Care and Outcomes."

Analysis of Nursing Clinical Decision Support Requests and Strategic Plan in a Large Academic Health System

OBJECTIVES

To understand requests for nursing Clinical Decision Support (CDS) interventions at a large integrated health system undergoing vendor-based EHR implementation. In addition, to establish a process to guide both short-term implementation and long-term strategic goals to meet nursing CDS needs.

MATERIALS AND METHODS

We conducted an environmental scan to understand current state of nursing CDS over three months. The environmental scan consisted of a literature review and an analysis of CDS requests received from across our health system. We identified existing high priority CDS and paper-based tools used in nursing practice at our health system that guide decision-making.

RESULTS

A total of 46 nursing CDS requests were received. Fifty-six percent (n=26) were specific to a clinical specialty; 22 percent (n=10) were focused on facilitating clinical consults in the inpatient setting. "Risk Assessments/Risk Reduction/Promotion of Healthy Habits" (n=23) was the most requested High Priority Category received for nursing CDS. A continuum of types of nursing CDS needs emerged using the Data-Information-Knowledge-Wisdom Conceptual Framework: 1) facilitating data capture, 2) meeting information needs, 3) guiding knowledge-based decision making, and 4) exposing analytics for wisdom-based clinical interpretation by the nurse.

CONCLUSION

Identifying and prioritizing paper-based tools that can be modified into electronic CDS is a challenge. CDS strategy is an evolving process that relies on close collaboration and engagement with clinical sites for short-term implementation and should be incorporated into a long-term strategic plan that can be optimized and achieved overtime. The Data-Information-Knowledge-Wisdom Conceptual Framework in conjunction with the High Priority Categories established may be a useful tool to guide a strategic approach for meeting short-term nursing CDS needs and aligning with the organizational strategic plan.

Advances in website information resources to aid in clinical practice

The World Wide Web, which has been widely implemented for roughly two decades, is humankind's most impressive effort to aggregate and organize knowledge to date. The medical community was slower to embrace the Internet than others, but the majority of clinicians now use it as part of their everyday practice. For the practicing oncologist, there is a daunting quantity of information to master. For example, a new article relating to cancer is added to the MEDLINE database approximately every 3 minutes. Fortunately, Internet resources can help organize the deluge of information into useful knowledge. This manuscript provides an overview of resources related to general medicine, oncology, and social media that will be of practical use to the practicing oncologist. It is clear from the vast size of the Internet that we are all life-long learners, and the challenge is to acquire "just-in-time" information so that we can provide the best possible care to our patients. The resources that we have presented in this article should help the practicing oncologist continue along the path of transforming information to knowledge to wisdom.

Instantiating informatics in nursing practice for integrated patient centred holistic models of care: a discussion paper

AIM

A discussion on how informatics knowledge and competencies can enable nursing to instantiate transition to integrated models of care.

BACKGROUND

Costs of traditional models of care are no longer sustainable consequent to the spiralling incidence and costs of chronic illness. The international community looks towards technology-enabled solutions to support a shift towards integrated patient-centred models of care.

DESIGN

Discussion paper.

DATA SOURCES

A search of the literature was performed dating from 2000-2015 and a purposeful data sample based on relevance to building the discussion was included.

DISCUSSION

The holistic perspective of nursing knowledge can support and advance integrated healthcare models. Informatics skills are key for the profession to play a leadership role in design, implementation and operation of next generation health care. However, evidence suggests that nursing engagement with informatics strategic development for healthcare provision is currently variable.

IMPLICATIONS FOR NURSING

A statistically significant need exists to progress health care towards integrated models of care. Strategic and tactical plans that are robustly pragmatic with nursing insights and expertise are an essential component to achieve effective healthcare provision. To avoid exclusion in the discourse dominated by management and technology experts, nursing leaders must develop and actively promote the advancement of nursing informatics skills. For knowledge in nursing practice to flourish in contemporary health care, nurse leaders will need to incorporate informatics for optimal translation and interpretation.

CONCLUSION

Defined nursing leadership roles informed by informatics are essential to generate concrete solutions sustaining nursing practice in integrated care models.

The Evolution of Data-Information-Knowledge-Wisdom in Nursing Informatics

The data-information-knowledge-wisdom (DIKW) model has been widely adopted in nursing informatics. In this article, we examine the evolution of DIKW in nursing informatics while incorporating critiques from other disciplines. This includes examination of assumptions of linearity and hierarchy and an exploration of the implicit philosophical grounding of the model. Two guiding questions are considered: (1) Does DIKW serve clinical information systems, nurses, or both? and (2) What level of theory does DIKW occupy? The DIKW model has been valuable in advancing the independent field of nursing informatics. We offer that if the model is to continue to move forward, its role and functions must be explicitly addressed.

Empowered Consumers and the Health Care Team: A Dynamic Model of Health Informatics

This article presents a dynamic new model of health informatics. Within the model, the focus of health informatics changes from the provider to the consumer and incorporates the dynamic relationship of technological change to health care. Bioinformatics is the scientific discipline that is translated into care through the practice of health informatics. The loci of health informatics practices are the consumer (consumer informatics), the patient (clinical informatics), and the community (public health informatics). The continuum from individual to community interacts with and contributes to health care technology, which is represented as a constantly changing progressive wave.

Nurses' Wisdom in Action in the Emergency Department

Nurses seek to understand better what practicing with wisdom means and how to apply wisdom to practice; however, the experience of wisdom in nursing has not been well defined or researched. This study was designed to understand how emergency department (ED) nurses construct the meaning of wisdom within the culture of clinical nursing practice. Using Charmaz's constructivist grounded theory methodology, we developed a preliminary theory capturing the experience of wisdom in practice. The core theoretical model focuses on two juxtaposed processes, technical and affective, and is grounded in expertise. Significant findings were the recognition of affective categories, such as emotional intelligence, required to practice using wisdom. Results reinforce and extend the current wisdom literature and provide a new perspective on wisdom in practice in a nursing context.

The Application of Informatics in Delineating the Proof of Concept for Creating Knowledge of the Value Added by Interprofessional Practice and Education

The resurgence of interest in the promise of interprofessional education and collaborative practice (IPECP) to positively impact health outcomes, requires the collection of appropriate data that can be analyzed and from which information and knowledge linking IPECP interventions to improved health outcomes might be produced and reported to stakeholders such as health systems, policy makers and regulators, payers, and accreditation agencies. To generate such knowledge the National Center for Interprofessional Practice and Education at the University of Minnesota has developed three strategies, the first two of which are: (1) creating an IPECP research agenda, and (2) a national Nexus Innovation Network (NIN) of intervention projects that are generating data that are being input and housed in a National Center Data Repository (NCDR). In this paper, the informatics platform supporting the work of these first two strategies is presented as the third interconnected strategy for knowledge generation. The proof of concept for the informatics strategy is developed in this paper by describing: data input from the NIN into the NCDR, the linking and merging of those data to produce analyzable data files that incorporate institutional and individual level data, and the production of meaningful analyses to create and provide relevant information and knowledge. This paper is organized around the concepts of data, information and knowledge—the three conceptual foundations of informatics.

Electronic health records (EHRs): supporting ASCO's vision of cancer care

ASCO's vision for cancer care in 2030 is built on the expanding importance of panomics and big data, and envisions enabling better health for patients with cancer by the rapid transformation of systems biology knowledge into cancer care advances. This vision will be heavily dependent on the use of health information technology for computational biology and clinical decision support systems (CDSS). Computational biology will allow us to construct models of cancer biology that encompass the complexity of cancer panomics data and provide us with better understanding of the mechanisms governing cancer behavior. The Agency for Healthcare Research and Quality promotes CDSS based on clinical practice guidelines, which are knowledge bases that grow too slowly to match the rate of panomic-derived knowledge. CDSS that are based on systems biology models will be more easily adaptable to rapid advancements and translational medicine. We describe the characteristics of health data representation, a model for representing molecular data that supports data extraction and use for panomic-based clinical research, and argue for CDSS that are based on systems biology and are algorithm-based.

The eHealth Enhanced Chronic Care Model: a theory derivation approach

BACKGROUND

Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools.

OBJECTIVE

The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses.

METHODS

Using Theory Derivation processes, we identified a "parent theory", the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms "CCM or Chronic Care Model" AND "eHealth" or the specific identified components of eHealth. Additionally, "Chronic Illness Self-management support" AND "Technology" AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM.

RESULTS

We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider.

CONCLUSIONS

The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.

Nurses as knowledge workers: is there evidence of knowledge in patient handoffs?

Patient care handoffs are critical to ensuring continuity of care and patient safety. Current definitions of handoffs focus on information, but preventing errors and improving quality require knowledge. The objective of this study was to determine whether knowledge and wisdom were exchanged during medical and surgical patient care handoffs and to discover how these were expressed. The study was a directed content analysis of 93 handoffs using the data/information/knowledge/wisdom framework. Results indicated knowledge was present in all handoffs, comprising 41% of the phrases across the two types of units. No wisdom was coded. The percentage and types of knowledge phrases differed between medical and surgical units. Handoffs could be more knowledge based by linking handoff content to patient problems and goals. Future handoffs could be computationally derived, context-specific, and linked to problem-focused care plans and patient summaries. Improved data visualization and cognitive support are needed.

Meaningful use of data in care coordination by the advanced practice RN: the TeleFamilies project

Meaningful use of electronic health records to coordinate care requires skillful synthesis and integration of subjective and objective data by practitioners to provide context for information. This is particularly relevant in the coordination of care for children with complex special healthcare needs. The purpose of this article is to present a conceptual framework and example of meaningful use within an innovative telenursing intervention to coordinate care for children with complex special healthcare needs. The TeleFamilies intervention engages an advanced practice nurse in a full-time care coordinator role within an existing hospital-based medical home for children with complex special healthcare needs. Care coordination is facilitated by the synthesis and integration of internal and external data using an enhanced electronic health record and telehealth encounters via telephone and videoconferencing between the advanced practice nurse and the family at home. The advanced practice nurse's ability to maintain an updated plan of care that is shared across providers and systems and build a relationship over time with the patient and family supports meaningful use of these data.

Nursing informatics: decades of contribution to health informatics

OBJECTIVES

In this paper we present a contemporary understanding of "nursing informatics" and relate it to applications in three specific contexts, hospitals, community health, and home dwelling, to illustrate achievements that contribute to the overall schema of health informatics.

METHODS

We identified literature through database searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library. Database searching was complemented by one author search and hand searches in six relevant journals. The literature review helped in conceptual clarification and elaborate on use that are supported by applications in different settings.

RESULTS

Conceptual clarification of nursing data, information and knowledge has been expanded to include wisdom. Information systems and support for nursing practice benefits from conceptual clarification of nursing data, information, knowledge, and wisdom. We introduce three examples of information systems and point out core issues for information integration and practice development.

CONCLUSIONS

Exploring interplays of data, information, knowledge, and wisdom, nursing informatics takes a practice turn, accommodating to processes of application design and deployment for purposeful use by nurses in different settings. Collaborative efforts will be key to further achievements that support task shifting, mobility, and ubiquitous health care.

Exploration of the e-patient phenomenon in nursing informatics

The availability of health information on the Internet has equalized opportunities for knowledge between patients and their health care providers, creating a new phenomenon called the e-patient. E-patients use technology to actively participate in their health care and assume higher levels of responsibility for their own health and wellness. This phenomenon has implications for nursing informatics research related to e-patients and potential collaboration with practitioners in developing a collective wisdom. Nursing informatics can use the data, information, knowledge, and wisdom (DIKW) framework to understand how e-patients and clinicians may achieve this collective wisdom. Nurse informaticists can use constructivism and Gadamerian hermeneutics to bridge each stage of this framework to illustrate the fundamentals of patient and clinician interactions and commonality of language to achieve a collective wisdom. Examining the e-patient phenomenon will help nurse informaticists evaluate, design, develop, and determine the effectiveness of information systems used by e-patients. The Internet can facilitate a partnership between the patient and clinician and cultivate a collective wisdom, enhanced by collaboration between nurse informatics and e-patients.