Nursing informatics and healthcare go hand-in-hand these days. Technology in nursing practice is not new, but the ways in which technology exists and contributes to healthcare is. One change is the use of the electronic health record (EHR). At the end of 2013, 80% of hospitals and 50% of healthcare providers implemented EHRs.1 But, the EHR is only one aspect of nursing informatics, which has become an essential aspect of nursing practice in all settings, including clinical practice (e.g., patient monitoring devices, work lists to help with planned nursing interventions), nursing administration (e.g., automated staff scheduling, quality assurance and outcomes analysis), nursing education (e.g., computerized-assisted instruction, distance learning online courses), and nursing research (e.g., computerized literature searching).2 Nursing informatics is defined as the specialty that "integrates nursing science with multiple information and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice."3 There are many roles nurses fulfill in nursing informatics. An essential one is that of the nurse informaticist or informatics nurse specialist. In your capacity as the INS, your responsibilities include the selection of computer systems, testing computer systems, educating and training end-users of computer systems, and the identification of computer technologies that can benefit nursing and patient care.2 Inherent in these responsibilities are many legal obligations. Some include:
- Developing sound policies and procedures for the use of the informatics system utilized in the facility;
- Adequately training and re-training end-users of the system;
- Requiring and strictly emphasizing patient safety as the No. 1 priority when the informatics system is used for patient care;
- Establishing a zero tolerance for sharing passwords or codes to gain access to the informatics system, including developing codes of conduct prohibiting any unauthorized use of codes or passwords and resulting ramifications (e.g.,termination);
- Educating all health team members to use the system as it is intended to be used (e.g., not entering information in the system or attempting to bypass it);
- Securing the privacy and confidentiality of all information in the system, pursuant to federal and state laws regulating these rights;
- Requiring employees to sign confidentiality and privacy agreements restricting access to identified healthcare information and restricting access to healthcare information only as part of the employee's job;
- Requiring any printouts from the system be shredded immediately when no longer needed;
- Emphasizing age-old and proven principles of good documentation that was used with hard copy charting; and
- Reducing, insofar as possible, potential medical and nursing errors that may arise with the system used for patient care documentation (e.g., improper use of copy and paste features, accidental click of the mouse when using a check list for medications).5
When these, and other, legal obligations are not met, the facility and the INS may face numerous lawsuits. Potential legal court cases include data breaches; accusations of modification of EMRs; inadequate templates for diagnoses, medications and treatment plans; failure to select appropriate software for use when documenting patient care; and failure to provide ongoing evaluation of current systems.6 As an INS, keeping abreast of new developments in nursing informatics, maintaining certification, participating in continuing education, active involvement in nursing informatics professional associations, and maintaining standards of practice in nursing informatics can help avoid these potential legal pitfalls and, at the same time, establish and maintain a health information system in your facility that is useful in ensuring good patient care.7
FOOTNOTES
- Mary Beth Mitchell (2015), "We Save Lives: An Informatics Perspective On Innovation," 45(2) Nursing 2015, 20-21. Available at: http://www.nursingcenter.com/JournalArticle?Article_ID=2706436&Journal_ID=54016&Issue_ID=2706379.
- Katherine Bengan (2015), "Nursing Informatics: A Needed Role in Today's Health Care," Nursing Examiner, 2-6. Available at: http://www.nursingexaminer.com/nursing-careers/nursing-informatics.
- Nursebooks.com (2014), "Nursing Informatics: Scope and Standards of Practice," 2nd Edition, 1. Available at: http://www.nursesbooks.org/Main-Menu/Standards/H--N/Nursing-Informatics-2nd-Ed.aspx.
- Nancy J. Brent (2013), "Legal Issues Every Nurse Informatist Should Consider, 1." Available at: www.himss.org/news/NewsDetail.aspx?ItemNumber=18399.
- Molly Gamble (2012), "5 Legal Issues Surrounding Electronic Medical Records," Becker's Hospital Review, 1-5. Available at: http://www.beckershospitalreview.com/legal-regulatory-issues/5-legal-issues-surrounding-electronic-medical-records.html.
- Alicia Gallegos (2012), "Legal Risks of Going Paperless," American Medical News, 1-4. Available at: amednews.com.
- Brent, supra note 4.
