Nursing Informatics in Asia

  Nursing Informatics in Asia

• Since computers were first introduced into the health into the healthcare sectors of Asian countries in the 1970's. there have been exciting developments in healthcare informatics associated with the rapid growth in information and communication technology. The first applications of information technology in healthcare in Asian countries were in administration billing and insurance. Now these countries are moving toward implementing paperless electronic health records.
• NI have varied between Asian countries ,but all governments have played a very important role in introducing information technology into the healthcare sector by providing funds,developing infrastracture,and introducing policiesto promote its use. Professional organization have also played an important role.
• The adoption of informatics in Asian countries usually began as a vision by a group of individuals in the governmennt or a professional organization,who promoted the use of information technologies to support nurses in all areas of nursing practice. 
• As information technology has become indispensable to daily activities of healthcare professsionals. more and more nursing  schools are beginning to realized the importance of providing informatics courses ot nurses.
• Basic computer literacy education is now a part of nursing education in most Asian countries,and graduate programs majoring in NI are also available now in some countries, such as south Korea and Taiwan.
• reports of research into NI began to appear in the domestic Asian nursing journals in 1990's, but such research is still in its infancy. In most countries, information technology first appeared as an educational tool, following  by its use in clinical practice  in applications such expert systemes and electronic nursing records.
• this use in clinical practice lead to the development of standards becoming a favorite research topic.
• events  external to the nursing profession catalyzed the adoption of informatics links have assisted these begining and their progression. The progress in japan, China, and South Korea has been expedited by the hosting of the International Medical Informatics Association(IMIA) triannual conference in 1980,1989,and 1997 respectively.
• the formation of the Asia Pacific Medical Informatics Association in 1993 helped launch national healthcare informatics association in  China, Japan, South Korea, and Thailand due to the hosting of triaannual conferences in the Pacific Rim.The China, Japan ,and Korea Medical Informatics Association (formed in 1999) organizes conferences,seminars and workshops once a year and creates forums by for the sharinng of experience and knowledge among both experts and users in these three countries.Asian Nurses who are interested in promoting Informatics to their profession need to link outwith this network.

Korea

• South  Korea compress eight provinces with seven metropolitan cities and the total population was about 47 million in 2002.
• the population is predominantly in urban areas,with 21% living within the Seoul metropolitan area. 
• There are currently 190,720 licensed midwives and nurses of whom 81,478 are practicing and 23,331 of these are situation the Seoul metropolitan area.
• Health Informatics in South Korea has growth considerably in recent years professional outreach activities.
• In the contrast,computers were not used in nursing education and research in 1993 and NI was not taught in universities until 1994 
• In 1993 ,The Nursing Informatics, special interest group was organized in the KOSMI,since the nursing informatics group has held its own session at the biannual  conferences of the KOSMI.
• Nursing has been highly visible in the KOSMI by the presentation and publishing of papers on the used of computers in nursing of these conferences and in the journal of the KOSMI.
• the   IMIA conference MIDINFO98,held in Seoul provided an excellent opportunity  for Korean nurses to become acquainted by NI.
• currently there are modern 200 active nurse members in the KOSMI of 1000 active members. 
• further momentum for NI has been coming from funding for a NI study group provided by the Korean science and engineering foundation since 1998 .
• Activities of the study group include journal reviews and research activities such as survey studies of NI education and computer applications in nursing practice in Korean hospitals.
• Korean nurses have attended and participated in many international conferences promoted or supported by IMIA or IMIA-NI group  since 1989.
• Korean Nurses represented the country at the IMIA-NI group of 1995,since then Korea has sent a representative to the group and participated actively in developing and furthering NI.

Use of Information Technology in Clinical Practice

According to the report published by the Korea Health Industry Development Institute in 2000,100% of teaching hospitals,and 75% of private clinics now have hospital information systems ( Korea Health Industry Development Institute,2000). Such a high implementation rate is believed to have been initially driven by financial factors associated with medical insurance claims,with the focus subsequently shifting to all areas of patient care when clinicians began to use computers in their practice. A recent study shows that all of the teaching hospitals and about 40% of general hospitals  in Korea are using order Communication systems (Kwak 2000), which enable physicians to communicate with other  departments for practiced -related requisitions and the retrieval of data.In addition, about 95% of teaching hospitals and 20% of general hospitals are equipped with pictures archiving and communication system(PACS's). There has been a great deal of interests among healthcare organizations in acquiring the system since the government announced high reimbursement rates for diagnostic radiology examinations using PACS in 2000, and PACS are now one of the most common information technology systems in South Korea hospitals. Hospitals in South Korea are now beginning to implement paperless electronic medical record systems.

The use of computers in clinical nursing practice in Korea began first in medium-sized hospitals. This hospitals initially used computers mainly for administration and billing, as did most hospitals in other countries, but later a patient-care component was added. This systems allowed physician to enter medical orders directly into the computers, and major ancillary department could receive requisitions and enter test results. The nurses work list could be viewed on screen or printed so that the nurses did not need to copy medication schedules or care activities into the cardex or write paper messages.

Other Korean hospitals were also pursuing this level of automation.Nursing information system proliferated when large hospitals ( with more than 1000 beds) began opening in the mid-1990's. These new hospitals  were equipped with nursing information systems when they first opened. They included unique nursing activities such as nursing assessments, nursing care plans, and patient classifications, in addition to nursing activities related to billing, managerial and coordinating activities and physician delegated tasks.

A home healthcare system for community-based clinical practiced was developed by the Home Healthcare Team at the College of Nursing, Seoul National University ( Park et al.,2000).Home healthcare nurses use laptop computers to note and check medication and progress in electronic patient records,and to communicate electronically with other home healthcare team members.

Health Information Education

As information technology has become indispensable  in healthcare and its impact on the daily activities of healthcare professionals has become significant, schools are beginning to realize the importance  of health informatics  education for clinicians. According to the recent surveys on health informatics and computer education programs in South Korean medical  and nursing schools, about 25%  of  medical schools and 21% of nursing schools offer health informatics courses,while the remainder offer introductory computer courses( Park, 2002). The course contents vary a great deal form school to school, and the instructors are mostly self-taught in these subjects. This indicates  that there is a a need for standardization of health informatics courses  for baccalaureate programs based on tasks of healthcare  professionals, together with graduate programs to produce qualified health informatics educators.

Most nursing schools in Korea are adding  informatics to graduate curricula so that  graduates students can take informatics courses as an elective. The graduate specialization program in NI in Korea was first introduced at Seoul National University in 2001. This program is the only one in Korea that awards a master's degree in NI.

Research

 Most papers presented at KOSMI conferences and published in the Journal of the  KOSMI since 1991 have addressed the application of commercially available programs, with more recent papers discussing the use of computers as the total for nursing education.Distance education  using the Internet has also been  described  (Park, Cho and Kim,1998;Cho and Park,1998; Kim et al.,2000; Choi et al.,199. The trend toward system  integration in the health industry in the late  1990's lead to more articles and presentations on standardization. Papers on the  standardization of nursing vocabulary and nursing documentation forms have also appeared ( Park et al., 1999;Park and Cho ,2000;Coenen et al.,2001). 

Another  popular research area is the use of artificial intelligence in nursing  diagnosis ( Park ,Lee and Song,1995; Kim 1998;Yoo et al.,1998).  The use of personalized digital assistants (PDAs) in hospital and home health-care settings along with the  standardization and the use of Web-based electronic patient records and current areas of interest( Hyun et al.,1999,Cho and Park ,2003).

Standardization Activities 

 There are current efforts to implement a single,integrated healthcare and nursing terminology in South Korea, the primary motivation for which is compatibility of data, clinical documentation, and research outcomes across the country.There are Korean representatives  actively involved in international initiatives toward this end, such as International Organization for Standardization/ Technical Committee 215 (ISO/TC215) and Health Level Seven (HL7).

Administrative information systems in the healthcare sector essentially use the Koren Standard Classification of Diseases ( the Korean version of the International Classification for Disease  [ICD]10), while clinician  information systems are beginning to use more concept -oriented terminology such as the SNOMED ( Systematized Nomenclature of Medicine). The majority of existing nursing terminologies, such as the North American Nursing Diagnosis Association (NANDA) Taxonomy 1 and 2 ,Nursing Interventions Classifications (NIC), Home Healthcare Classification (HHCC), the Omaha system , Nursing OUtcomes Classification( NOC), and International  Classification for Nursing Practice ( NCP), have been translated into Korean and standardized. Among these terminologies , the NANDA is the most frequently used in nursing education, and the 3N ( NANDA,NIC-NOC) and INCP are most frequently used in clinical practice for electronic nursing record systems in Korea.

Government Initiatives

 The Korean government has contributed to the development  of health informatics by providing funding or other incentives  and guidelines in telemdecine, emergency medical systems, infectious diseases reporting systems,and standardization. The Korean government has contributed to the implementation of a nationwide information highway, with the Ministry of Information and Communication having funded information, highway projects since the early 1990's. There are two information highways  available;(1) the South Korea  Advanced Research Network, which  is mainly used for research activities and (2)  a nationwide commercialized network built by telecommunication companies(Korea Ministry of Information and communication,2002). These network interconnect 12 metropolitan areas in South Korea at 622 Mbps and smaller surrounding cities are connected at 155 Mbps.Individual  users at their home  can use ADSL( asynchronous digital subscriber line) to connect to the Internet at a speed of 1-8 Mbps, and currently more than 50% of South Korean  homes have ADSL connections. This is highest percentage  among all countries of the world.

 The Korean Ministry of Health and Welfare established a long-term plan for national health and welfare network(NHWN)in 1993. The NHWN cover six areas; public health, hospitals and clinics, health insurance, food and drugs, national pension, and health and welfare administration. Public health was selected as the top-priority project in 1994, to be carried out  in the three phases; 

• The first phase( form 1994-1997) computerized the administrative  and patient-care activities of health centers.
• The second phase( from 1998-2001) developed infrastructure for the public health network, integrating network systems among health centers, health subcenters, and primary healthcare posts.An electronic data interchange systems between the public healthcare facilities and the health insurers was developed for health insurance claims.Possible ways of linking the NHWN to the city,country, and district networks of the Ministry of Governmental Affairs and Home Affairs were studied.
• The current third phase, which started in 2001, involves the development of data warehousing at the level of major cities and provinces. Once this system is implemented successfully,it will be expanded to the whole of South Korea.

Professional Outreach

Since its foundation in1987, the KOSMI has played a very important role in promoting and developing health informatics by holding biannual academic conferences,various seminars ,workshops, and open forums, and by publishing journals.KOSMI has also offered educational programs for beginners in health informatics.

 Organization such as the Korean medical Association and the Korean Nurses Association have also played a significant roles by including health informatics in their continuing education programs.Another healthcare informatics expert group, the Health Informatics Standardization Committee,serving as the South Korean technical advisory group of the ISO/TC215, has held open forums and published health information standards.

  The IMIA has contributed significantly to furthering the knowledge of South Koeran healthcare professionals about worldwide trends in health informatics. These individuals have attended and participated in many international conferences promoted or supported by the IMIA since 1989.

Technologgy Trends

 The rapid growth in the number of mobile telephone users( currently estimated to be around 65% of the total population) and the advance in wireless local area network(LAN) technology have lead to mobile computing in healthcare becoming a popular issue in South Korea, with many healthcare organizations testing its feasibility in special wards. The main users of the systems currently are nurses attending patients at bedsides, but this will soon be extended to other healthcare professionals. Although PDAs, Web pads, and notebook and tablet computers are all siutable mobile computing platforms ,users favor notebook computers with wireless LAN connections because of their larger screen size and easier-to-use interface.

The need for telemedicine continues to grow in Korea with the increasing numbers of elderly, patients with chronic diseases, and patients who are discharged early.Many telemedicine  system have been tested over the past 10 years, one of which is a teleconsultation system initiated by the government. Such systems allow, for example , a generalist doctor at a healthcare center in a remote area to have a telepathology consultation with the specialists of a tertiary hospital. Another example of telemedicine is telecare at home at home, with the telecare center of Seoul National University Hospital and the telemedicine center of Gil Hospital being among the most active telecare at-home clinics( Yoo,2002). Telepractioners at these centers maintain special schedules for their remote clients. They set aside 1-2 days per week to take care of their clients using virtual reality technology via the Internet.Currently , the teleconsultation fee is  reimbursed  by health insurance,whereas the use of telecare-at-home clinics is not yet covered.

Japan 

the population of is about 127 million, which is about twice of the unit kingdom and half that of the united states. there are about 10,000 hospitals in japan, of which about 430 have more than 400 beds. about 750,000 nurses work at these hospitals, including 220,000 nurses aides and there about 260,000 medical doctors, 90,000 dentist and 23,000 pharmacist( ministry of health , labour and welfare, 2004). The healthcare delivery system in japan provides easy access to healthcare. all citizens can choose healthcare institutions and doctors freely, and their financial contribution to health insurance is proportional to their income.the insurance fee is deducted from monthly salary and pooled by each insurance union.insured individuals and families pay 20 and 30%, respectively of all health expenditure and the publicly funded health insurance pays the rest when a patient receives medical treatment in a hospital .the hospital receives reimbursement for the balance from the national health insurance.the Japanese government will contribute a maximum of 70,000 yen to the medical treatment of a person over 1 month.both the easy access to healthcare and low out-of-pocket cost in japan to help to provide the populace with a sense of security.

Health Informatics in Japan 

started the use of computer in healthcare during the late 1970s  following the increased of computers  in other industries.
Japan hosted the IMIA conference MEDINFO80 in 1980. The Japanese Association of Medical Informatics(JAMI) was founded at that time with the aim of supporting health informatics in Japan. Since then JAMI has held 24 annual and biannual academic conferences, and these conferences have contributed considerably to the progress of health informatics in Japan( JAMI ;1996;Kamiizumi and Ota,2004).Initially research was focused on computerized billing systems for medical fees,and the development of the use of personal computers at an individual level(JAMI,2004). The focused then shifted to research and development of systems at the organizational level, such as hospital and regional information systems, and research into basic information technology ,for healthcare such as database design,network ,security, and data switching technology.The current focuses are ethical issues in health informatics ,medical,finances,and quality assurance.This illustrates that the scope of health  informatics has gradually expanded since it was first introduced into Japan during the 1980's.
Medical information departments in about 50 national university hospitals have made  the largest contribution to the development of health informatics in Japan. Each organization has been developing its own hospital information system,education and research( Supplement of national university medical information processing department liaison conference,1995-2003). This work helped Japan to determine the information technology, and mechanisms that were needed for healthcare applications , but their independence has hindered standardization in many healthcare fields.Standardization is one of the many problems in the use of healthcare information technology that needs to be resolved.

History of Nursing Informatics in Japan

The Third International Congress on Medical Informatics, MEDINFO80,organized by the IMIA,was held in Tokyo in 1980.This congress included a special  group on NI, which represented the beginning of NI in Japan( JAMI,1996;Kamiizumi and Ota 2004).This did not result in immediate progress in Japanese NI education,due to schools being vocationally oriented. However, in the late 1990's  nursing education in Japan rapidly shifted to  more academic orientation,and there are now  more than 100 universities offering graduate programs.Some baccalaureate programs and graduate  schools include NI courses in their curricula. NI was applied more in clinical practice  than in academic fields during the 1990's, with more nurses learning about utilizing computers in nursing practice  through the activities of medical information department setting in the national university hospitals.I t was also evident that clinical nurses presented more papers than academic researchers at the annual meeting of the JAMI.The annual Meeting for Nursing Information Systems that was established as a task force  of the JAMI also supports clinical practice,and most of its members are clinical nurses.The nursing  Division of the JAMI was established in 2000 and is managed by a team of clinical nurses and academic researchers.Several textbooks on NI have been published, but systematized NI education has not yet been implemented. The Japanese Nurses Association prepared a course of nursing information management first step of  a continuing education curriculum for ward managers.The standard textbooks was published on March 2004, and the lectures are researchers of health informatics and NI, and clinical nurses working at the hospital where hospital information systems were introduced.

Nursing Informatics Education

As on April, there were 486 professionals schools,31 junior colleges, 120 universities and 45 graduate schools in Japan ( Tokyo Academy,2004), compared to 461 professional schools74 colleges ,and 30 universities in 1994(Japanese Nursing Association 2002).This comparison illustrates that nursing education in Japan has shifted  from professional schools to universities and postgraduate education during the last 10 years.However,there are still very few universities  with separate NI programs.The increasing development  of hospitals information  systems in Japan has lead to discussions on the utilization of information technology in clinical nursing practice. continuous education  of NI is being emphasized,along with the promotion of the electronic records.However it is difficult to conclude that the curricula of nursing schools have reflected the changes in the society and clinical fields.Rather ,it appears that clinical practice is now more advanced than nursing education.
Universities provided elementary computer literacy education during the first half of 1990's but this become unnecessary thereafter due to introduction of computer education into elementary and junior high schools.Overall ,the teaching of computer literacy on document retrieval utilization of statistical processing,and Web utilization has increased, but barriers to the development of the NI remain in Japan.
(1) there are few researchers ad educators in NI,
(2)there is little development of educational tools, and 
(3)the cost of improving the network and computer environment is high.However,the importance of universities providing a satisfactory curriculum is being recognized due to the increasing importance of NI, with this being more so in graduate  schools than in baccalaureate education.

Nursing Informatics Research

• The main amount  of NI research is increasing in Japan , the two main purposes of which are improving, the quality and standardization of nursing practice. 
• NI was one of the main subject areas  of paper presentation at recent annual meeting of the Japanese Academy of Nursing (Japan Academy for Nursing Science ,2003), indicating that it was becoming one the major areas in nursing.
• There were many reports on research into the use of information technology as an educational tool during the 1990's and on the use of information technology o clinical practice ,especially on decision support system for nursing in hospital information systems and electronic health records(JAMI,2003).
• There has also been research into the use of information to prevent nursing-related accidents( Tsuruu et al.,2004) and into telenursing(Kawaguchi,Azuma and Ohta, 2004).
• research into nursing practice algorithms using thinking-aloud methods have begun in Japan.

Nursing Informatics Practice

• Becoming specialists in NI is useful when hospital information systems and electronic health records are introduced.However, the accreditation program of the Japan Nursing Association does not recognize the training for such specialists. Instead, the training of informatics nurses mainly occurs in hospital setting. 
• In each hospital ,nurses working on medical information are active in committees  and working groups.Most of them involve not only nursing -related work but also medical information-related work.
• Their lack of of formal technical education often causes difficulties,and hence it is predicted that the importance of nurses with NI education will increase.
• The JAMI began an accreditation program for "health care information technologists" in 2003.
• hospitals are looking for new  healthcare staff with knowledge of both healthcare and information technology who can control information flow.Although a healthcare information technologists is a healthcare professional with such training, it is necessary to distinguish between the roles of the Ni clinical nursing specialist and a healthcare information technologist. Informatics nurses will be expected to expand their  activities in healthcare when both professions are introduced in hospitals.

Japanese Government Initiatives and standards Development in Japan

• An "e-Japan strategy encompassing all Japanese ministries are related agencies in progressing now in Japan.
• The standardization of medical information is one of the main themes in the healthcare sector.
• The Ministry of Health Labor,and Welfare announced a grand design for healthcare, and set the following achievement goals for 2006( Panel on Healthcare and Medical Information Systems;2002):

1. electronic health records will be introduced into 60% of hospitals with more than 400 beds and into 60% clinics and
2. the electronic health expenditure payment system will be introduced into 70% of all hospitals,

• Standardization of the terminology used in electronic health records is a requirement for achieving this goal,and the Ministry of Health, Labor,and Welfare has begun a project for developing a national standard,which is publicly available on the Internet( The Medical Information Systems Development Center,2004). This is especially useful for hospitals introducing hospital information systems for the first time.
• The following 5 standards have already been completed:

1. 581 facilities now perform medical diagnosis using the ICD 10,
2. 330 facilities  have surgical and medical treatment standards
3. 5,700 clinical test have been registered in the clinical laboratory test standard
4. about 38,000 drug names have been registered by 203 enterprises,and 
5. about 210,000 medical supplies have been registered by 336 enterprises.

• Standardized symptoms, physiologic function  examinations, imaging test, dental terminology,and nursing terminology are currently under development, and nursing actions and observation items in nursing terminology are available to the public since the middle of 2004.
• The terminology used in nursing practice  has been collected, analyzed ,and redesigned. About 260 fundamental nursing practices have been identified and named in Japan.They have been categorized into daily-life care,family support,guidance and education , adjustment during organization, care in the usage of equipment, care for the terminally ill and the bereaved family, and others .
• The two hospitals were electronic health records using this nursing terminology were developed have utilized the terminology describing nursing care plan and nursing order ,and in the implementation of care;Continues 24-hour observation of nursing can be shared, indicating that the use of such a system is very useful for the medical profession.

China

• According to the Fifth National Census reported by the National Bureau of Statistics, the population of china was almost 1.3 billion in 2000.
• The population is aging fast, with those 65 years old  and older representing 6.96% of the population in 2000, compared to 5.57% in the 1990 census.
• There were 17,764 hospitals,5,275,000 healthcare professionals , and 1,266,000 registered nurse in China have baccalaureate  and 3 year diplomas , respectively(Nusing School Weizhuo Medical College,2004.)
• In China, the majority of the population is found in rural areas,and thus the overall healthcare level, stability of society, and economic development of the whole of China is influenced by healthcre services  in rural areas.
•  The primary healthcare systems in rural China typically involved cooperation at country,town, and villages levels.These systems include providing medical services, the training of healthcare staff, hygiene education, and the development of a patriotic health campaign.( Ma,2000).
• The SARS epidemic in China  lead to reconsideration's of the current healthcare systems in rural areas. Some Chinese consider that the system is not moving forward and that more effort should be devoted to epidemic prevention, and that a new system cooperative medical care and new salvation system of the poor should be set up to ensure  health in rural areas and enhance stability of society and economic  development of country.( Zong,2004)
• The SARS epidemic also lead to suggestions of an integrated system for disease control and prevention( Lou,Feng and Zhanf,2004).
• The health information infrastructure has improved dramatically in China since the initiation o the National 95 Plan.
• This plan include implementation of an National Medical Information Network, advances in constructing hospitals,information system as well as advances in community healthcare, health supervision, disease control , maternal and child healthcare, telemedicine  and distance medical education(Ministry of Health China,2003).
• The China Medical Informatics Association( CMIA) was founded in 1981. This is an academic group and is a members.
• There are 2 other professional societies related to medical information in China:

1. The Chinese society of Medical Information( under the chin medical association)
2. The Chinese  Hospital Information Management Association( under the Chinese hospital association).\

• The Chinese society of Medical Information was founded in 1993, and its activities include holding academic conferences and seminars, continuing education, and training.

Nursing Informatics System in China

• The development of nursing information management  systems began in China in late 1970;s.(Li et al., 2001) and they were first used in 1987( Nursing Center,Ministry of Health , China, 1995; Li et al.,.,1995; Fu ,2000).
• The first software implementation was a computer assisted primary nursing carre system( Nursing Care Center, Ministry of Health, China 1995).
• The development of information  management system for nursing in Chinese  traditional medicine began in 1994( Li et al., 2001).
• Many hospitals  in China now use nursing information systems, although there are no official statistics available.some examples include nursing information system for the management of nursing staff ,nursing operation work, continuing education,scientific research,and finance ad economics(Zhang,Fu, and Fan,1999;nursing information based on an army satellite project called the no.1 Project of PLA; and and Internet-based nursing information management system( Wang et al.,2001;Zhang et al.,2004).

History of Nursing Informatics in China

• Nursing informatics Special Interest Group with 20 hospital nurses was founded as branch of the CMIA in 1991. A year later an expert group for nursing information technology was founded by the nursing Department  of the Chinese Ministry of Health, its mission  being  to establish  criteria for nursing management and the training for nurse administrators for nursing information management(Nursing Center,Ministry of Health , CHina 1995).
• The first article referring to the term "nursing informatics science" appeared in China in 1999, and this lead to the application of information technology in the field of nursing science for education and research(Fan and Fu,2000;Fan and Li ,2000). The term NI was first used in Chinese literature in 2002(Jiang,2002).

Nursing Informatics Education

• higher nursing education was first introduced in 1983,and by 2001 there were 120 schools  with 3 year diploma programs,62 schools offering a baccalaureate,and 11 schools with master's programs( Nursing School of Weizhou Medical College,2004).At least one computer course is required at the baccalaureate level , and nursing student can select other computer courses as elective courses.
• According to a literature review , computer-assisted instruction began at nursing institutes in China during the mid-1990's, since then it has been used in baccalaureate and continuing education courses in the clinical nursing field(Zhu, Lu, and Yin ,1995;Jiang et al., 1998; Li et al.,2002).Distance learning is also being used for nursing continuing education  in China.The first distance learning program in China is a collaboration between China and Canada  run by the school of Nursing, (Tian Jin medical university in 1999) Zhou and Song,2001).

Nursing Informatics Research

NI research is at its infancy in China , with only 30 research particles published in domestic nursing journal form 1994-2004( with the key words related  to the use of computers in nursing and nursing information with the research areas of nursing practice,nursing management,and nursing education.

Nursing Informatics Practice

The used of NI in clinical practice in China includes nursing quality management ,staff management, nursing information management, and training clinical skills for staff nurses (Zhang, Cheng, and Qi,2003). Several experts systems  for nursing diagnosis,nursing care plan,and nursing assessment have been reported(Ji et al.,1994;Wang,1995;Zhang,Fu and Fan,1999).

The major weakness of nursing information management systems in China is lack of of national standards and low level of computer literacy and informatics skills exhibited by nurses(Nursing Center,Ministry of Health,China,1995).

Thailand

• Thailand is located in Southeast Asia with Burma,Cambodia,Laos, and Malaysia as neighboring countries.
• The country has a population of about 65 million living in 76 provinces.
• Even though most people work in agriculture ,major revenue of the country comes from service and industry( Economy,2004).There were 92 regional /general hospitals,707 community hospitals , and 9559 health centers across Thailand in 2004 ( Country health profile ,2004)
• the government  is currently launching  a universal Healthcare Coverage policy in order to improve the access to the quality of healthcare,as week as to contain healthcare expenditure.
• The Thai government is restructuring its healthcare system by placing more emphasis on primary care and health promotion.
• recently the government also  attempted  to develop a healthcare hu for international clients.These policies require changes  in human resources including nurses,since the demand for nurses in primary care settinsgs across the country is increasing to serve the population at large, as is that for nurses competent at working in hospitals serving international clients.
• NI was first introduced as small special interest groups and later expanded to the national level through the support of the Nurses' Association of Thailand , the World Health Organization,and the Ministry of Public Health (MOPH). This section describes the development of NI in Thailand between 1997 and 2004.

The Development of a Health Information System

In 1991 , the Thai MOPH began to implement a national  health information system,which included the development  of a nursing component.The former director of the MOPH Nursing Divisions,Mrs.Areeya Suppalak, considered it important to provide nurses with means of using information technology .Funding was received from the World Health Organization in 1999 as a result of collaborative effort between the Center  for Nursing Research at the Department of Nursing, The faculty of Medicine, Ramathibodi Hospital, Mahidol University,and the MOPH Nursing Division to develop the ideal nursing minimum data set(NMDS) and a preliminary nursing classification system(Phuphibul et al.,1999).The NMDS was identified as essential for developing and efficient nursing database.The project was expanded and the development of nursing classification system was later merged with the project of Nurses Association of Thailand for validating the alpha version of the INCP developed by the International Council of Nurses(ICN) International Council of Nurses,1999).

Nursing  Information System

•  A further to implement the INCP in the Thai nursing environment was developed, a collaborative software program called "Healthware 2000" by the MOPH Nursing Division for the collection and retrieval of nursing care data.
• Several hospitals serve pilot hospitals.However , the usefulness of the program was limited by it not being sufficiently user friendly and many nurses having limited knowledge of the ICNP.
• The unsuccessful implementation of Healthcare 2000 lead to the MOPH Division of Nursing further developing standard care plan using the ICNP, which will later adopted to computer implementation.This project is still in progress.
• Recently the Nurse's Association of Thailand under the leadership of Dr, Jintana Unipan provided seed money for the development of database including nursing diagnosis,nursing interventions,and nursing outcomes, in 10 leading diagnostic -related groups using a version of the beta INCP.
• The steering committee  for this project comprised nurses from seven speciality areas:medical nursing, surgical nursing,pediatric nursing ,maternal and child nursing, mental health and psychiatric nursing,community nursing and home healthcare,and cancer nursing.

• Although the preliminary Thai NMDS has been identified,challenges associated  with its development and implementation within the Thai national health information system remain.The evident continuity of the development  and implementation within the Thailand  demonstrates the commitment of the national  nursing organizations.

Taiwan

There was 610 hospitals and 175,000 healthcare professionals in Taiwan in 2002, serving a population of 22,5 million (Health and National Health Insurance Annual Statistics Information Service in Taiwan, 2004). The healthcare professionals included 34.3% registered nurses and 17.7 licensed practicing nurses.

History of Nursing Informatics in Taiwan

• The term NI was first used in Taiwan in 1990.At that time  the focus was on hospital information system providing nursing data such as nursing personnel information,care planning ,and scheduling.However,computers had been used in nursing education since the 1980's and the related nursing research into patient classification supported by the National Science Council began in the 1990's( Hsu et al.,1996.) Although a formal masters program focusing on NI was not available until 2001,the elective courses in baccalaureate and master's program s had started in the late 1990's. All baccalaureate programs included at least one or two computer courses. Currently ,some nursing students act as assistants for faculty in designing distance-learning classes.

Nursing Information System in Taiwan

Based on the unpublished results of a 2002 national survey, only 27% of hospitals had implemented nursing information systems,9% were developing them, and 24% were making plans to develop them ,whereas 40% were not planning to make any investment in nursing information systems in the near future.The pattern for long-term-care information systems was similar, in that almost 50% of long-term-care institutes were not planning any investment in information systems and only 19% had installed information systems.

Nursing Informatics Practice

• Computerized care plans are now common in clinical use.Moreover ,decision support systems to test the integration of medical diagnosis and nursing diagnosis , and expert systems implemented on PDAs for the emergency triage system have been reported.
• Patients Classification systems have also been applied for patient assessment (Hsu et al.,1996)These system designed to be integrated with costings so as to accurately define nursing fees.In addition PDAs have been used recently by nurses in their daily practice.
• nurses can chart vital signs and input and output other date at the point of care, and also access patient laboratory data,medication,or medical history without having to go back to nursing stations.(Li et al.,1998;Lin and Liao,2003).

Summary

The Healthcare environment in Asian countries is becoming inhospital due to high healthcare costs,increasing competition among  healthcare organizations,decreased funding from governments,and costumers with more sophisticated demands.The introduction of information systems and information technology can help healthcare organizations to survive under this difficult conditions.
healthcare informatics and the use of information  technology has proceeded rapidly in Asian countries,with exciting developments in the areas of clinical practice,informatics research and informatics education over the past decade. All of these developments have improve either directly or indirectly the productivity of healthcare professionals,the efficiency of the healthcare professionals.
It is clear that professional organizations play a major role in raising awareness ,education,and dissemination off knowledge in health informatics. This is becoming increasingly complex with the proliferation government initiatives spanning multiple government departments, which is a reflection of the multidisciplinary nature of health informatics .Nurse as the largest group of health professional ,have a major role to play.A sound knowledge of the many stakeholders will ensure that nurses can coordinate their efforts to ultimately benefit the healthcare consumer(our patients),communities ,and society as a whole.

Nursing Informatics in Pacific Rim,Asia and South america

Pacific rim

The evolution of NI has varied in each of the pacific Rim countries.The adoption of informatics usually began as a vision by one or more individual.Such people used any number of opportunities plus their leadership skills to promote and disseminate the use of information technology  to support nurses  in all areas of nursing practice .This occurred in healthcare ,education, and government organizations, as well as within the IT industry and via any number of new and existing professional organization . Events external to the nursing  profession frequently became the catalyst stimulating some type of activity by nurses towards the adoption of informatics.International and multidisciplinary links have assisted theses beginning and its progression. Australia, New Zealand , and Hong Kong have made considerable progress since the early 1980s,South Korea since the 1990s in this regard, although much remains to be done.Nurses in a number  of other countries  in this region have only just begun or have yet to learn about NI although introduction and use of these technologies in the industry is progressing  rapidly especially in Malaysia and Japan.

The Asia pacific Medical

Informatics Association was formed in 1993 as regional group of the international Medical Informatics Association . APAMI has helped launch national healthcare informatics association in Malaysia,Indonesia, and the Philippines and has generated  awareness about the field in India, Pakistan,Sri Lanka, and Fiji.Other member nations are Australia, Hong Kong , japan, Korea,New Zealand, the Peoples Republic of china, Singapore,Taiwan, and Thailand. Nurses who are interested  in promoting informatics to their profession need to link up  with this network.Evidenced  suggests that many nurses continue to have some difficulty in embracing these technologies to support their practice ( Ho and Hovenga,1999,2003). Furthermore it continues to be a challenge for many nurses to obtain appropriate education in informatics both  during their initial nurse education and as a component of post- nurse registration specialist courses.Notwithstanding these conditions,an increase in computer use by practicing nurses in Australia, New Zealand ,and other Asia Pacific countries is creating an awareness of the opportunities and gains to healthcare resulting from an increase in the use of computers ,information,and telecommunication technologies.Thus, the nurses in all health environments are becoming more dependent on electronic information.

Health and Nursing Informatics in New Zealand

• New Zealand’s total population is just over 4 million. These people are predominantly found in the urban areas,with the greater Auckland  area having over a third of the total population.
•  In 2003 ,there were 32,687 active registered nurses and midwives working in nursing and midwifery in New Zealand. With most of the nurses and midwives practicing  in Auckland ,this city by default becomes the focus of the drive for greater health informatics awareness.
  
• Notable changes have occurred  within New Zealand nursing legislation that impact on the roles and future                           of nurses. 
• Firstly , in line with international trends  in nursing workforce development , the Nursing Council of New Zealand established the new role of nurse practitioner. Then in 2003 , legislation was passed permitting nurse prescribing.
•  At this early stage there are only  a few of Nurse practitioners and fewer nurses prescribing ,but there is clearly a move toward further  postgraduate education to attain these new nursing roles. 
• The impact of globalization  has seen an increase  in the movement of nurses in and out  of New Zealand , which increases the challenges for the  Nursing Council  in terms of ensuring  safety practice  at the level expected in New Zealand  while not providing necessary barriers for overseas nurses.

 As part of ensuring standards of practice the government passed the Health  Practitioners Competence  Assurance  (HPCA) Act (2003). This Act came into force  in 2004 and replaced the Nurses Act of 1977. The HPCA Act 2003 requires each  health practitioner group to describe its profession  in terms of scopes of practice and to ensure the safety of the public by defining  the health services that health practitioners can perform.

 Changes  are continuous in the informatics arena and there are many sources and pressure for these.

The hub labeled “ informatics influences “ represents information  collection, since  this is seen as central  to nursing, informatics , and healthcare. The other entities  identified are significant  player’s in  New Zealand’s healthcare system, which  influences NI  and it’s development.

Health and Nursing Informatics  in Australia

• Australia is a federation of eight states and territories. It has a population of just fewer than 20 million .
• Approximately 71% of all it’s households are located in inner and outer urban and provincial areas, mostly near cities on the coast.
•  In 2001 ,the national census indicated that there were 1,259 nursing workers per 100,000 population where 51%  worked less than 35 hours per week ( AIH &W,2004a,p.229)

• Around 225,000 registered (80%)  and enrolled (20%) nurses  are employed in acute care hospitals (65%), aged and community care (35%) in Australia. Of these 89% are employed as clinical nurses mostly within the following specialities : medical surgical(30%), geriatrics and gerontology (17%),operating  theather  and related nursing (7%) , midwifery, obstetrics and gynecology(7%),and mental health (7%).(Karmel and Li,2002). 
• The trend suggest we increasingly need a greater proportion of nurses in the aged and community care sectors as a result of projected population demographic changes. 
• As a consequence of the globalization of the profession, Australia's  contribution to international education,the resultant  workforce mobility, economic growth, and changes in the healthcare industry  resulting  from technology  and in informatics advances, changes are being witnessed in the nursing workforce.
• Credentialing and accreditation  of  nursing specialties is now  being promoted.Nursing  specialty and other organization have developed and adopted practice standards, competencies,guidance for curricula development , and various professional  development program. 
  
• Australia has more than 50 specialty nursing organizations, where the health care informatics spacial interest group(HISA NI sig) is  one of these.
• Most have developed a set of specialty competencies and they provide credentialing service. Following the November 2003 Australia Health ministers conference it was announced that a national nursing taskforce  would be established to drive major nursing education and workforce reforms as recommended by a previously  undertaken national review of nursing education. 
• Consequently the HISA NI Sig has been funded to develop a strategic NI capacity building, and a plan for nursing professions engagement with the Australian government and its informatics agenda .

Healthcare funding framework

The government ,through  the ministry of health chiefly funds healthcare in New Zealand. Overall ,the funding healthcare in New Zealand is driven by business requirements,where information is used as the basis for cost-effective quality care, given limited resources.

Healthcare is available for all resident New Zealanders via  a National System. The cost of every consultation with the general practitioner is subsidized by the government. Tertiary care is almost totally publicly funded . There  remains in New Zealand an impression that if  you have an accident or are acutely sick, then good quality public hospital care will be available. There is, however,competition between private and public healthcare in the primary and secondary arena. Elective surgery is more often provided in the private sector , although it may be funded by the public sector ,as the public hospitals struggle to cope with long waiting lists and beds full of acutely ill and injured people. The role of the private sector has increased significantly. In 1999,private insurance funded about 6% of healthcare compared with just 2% ten years ago, and given the aging population, improved options of health treatment, an increasing demands yet limited public budgets. The cost of private insurance is rising with premiums predicted to increase faster than the general cost of living. This means health insurance cost the individual more and there is a widening gap between those who need and those who can afford private healthcare.

The government also controls healthcare provision and funding through agencies such as the Accident Compensation Corporation ( ACC). The ACC provides a rage of health benefits and subsidized  to assess individuals in the event of accident. The establishment of the ACC as virtually eliminated suing for compensation in the event of an accident covered by the ACC. Information is colliated about the nature and costs associated with accidents. ACC funding is provided through levy on employers and employees. That more recently ACC has targeted accident prevention as an incentive  ,charging more to those companies and organizations that has employees/member accidents.

All prescription-related medicines are regulated the government thought Pharmac. Subsidized are available on a rage of medicines, although only a few options of each drug classification maybe subsidized by Pharmac. The public can purchase an increasing number of over the country remedies and increasing need for drug  information for medical practitioners,nurses and  the public.

In Australia work began in collaboration with Professor Fetter from Yale University during the 1980’s to develop the patient classification systems to describe the care mix services by healthcare organizations.

Since 1992 ,the Australian Refined  Diagnosis Related Group(AR-DRG) has been in use first for  the purpose of monitoring and comparison of hospital activity and later for costing and funding purposes. This Australian Hospital Information, Performance Information Program relies on data obtained from individual patient records, including the ICD-10-AM codes. A number of case- mix  systems are used in to suit a variety of patient populations. Service weights to reflect the cost of providing various hospital-based services including nursing were developed and currently in the process of being updated.  These are included in various funding formulas adopted . This case-mix system has been adopted by Germany and is being considered for adoption by other countries.

Health spending continues increase, By 2001-2002 this amounted to 9.3 % of the gross domestic product (GDP) compared with 8.9% in 1992-2000. In 2001 -2002 , the Australian

government spent 46.3% primarily on health research ,aged care,and medical services.All taxpayers contribute a 1.5% Medicare levy and high income earners who do not  have private health insurance,pay an additional 1%. States,territory and local governments spent 22.3% mainly on community and public health  services. The cost of public hospitals is shared by all governments  in accordance with specifically negotiated healthcare agreements. Nongovernmental sources such as third party payers and individual contributions amount of 31.4%. This funds is all private hospital care. The Australian  government manages Pharmaceutical Benefits Scheme (PBS) which is jointly funded by them and non-government sources(AIH&W,2004a,pp.242-247).

Professional Organization and Government Advisory Groups

Both New Zealand and Australia have many health informatics and related professional organizations and groups advising various government departments and specific projects. There tends to be a considerable over-lap of members between these.

New Zealand Health Informatics Groups

There are number of informatics interests groups in New Zealand ,each with slightly different focus.   Health informatics New Zealand (HINZ) is a national ,not-for-profit organization whose focus is to facilitate improvements in business process and patient care in  the health sector through the application of  appropriate information technologies. HINZ ,a new organization ,emerged in September 2000 from two health informatics organizations: Nursing Informatics New Zealand (NINZ) and New Zealand Health Informatics Foundation (NZHiF). NI was originally formed in 1990 and NZHiF was originally formed in 1994.HINZ does not compete with existing organizations or activities.,but assists network key and influencial partners to improve the effectiveness of health informatics business in New Zealand .HINZ act as a single portal for the collection and dissemination of information about the New Zealand Health Informatics Industry. Membership is for anyone who has an interests in health and informatics and wants to be a part of an organization


that can provide relevant up-to date information about health informatics. HINZ holds an annual conference in collaboration with other main health IT organizations.

HINZ ,in conjunction with other professional health-related groups such as New Zealand Health Information Technology Cluster,New Zealand Institute of Management ,and New Zealand Health Level 7(NZHL7) Users Group (NZHUG), jointly organizes an annual national conference as well as seminars. 

 New Zealand Health Informatics Groups

• HINZ -Health Informatics New Zealand (HINZ) as a national ,not- for-profit organization whose focus is to facilitate improvements in business processes and patient care in the health sector through the application of appropriate information technologies.HINZ has established working groups to mirror those within the International Medical  Informatics Association Special Interest Group in Nursing Information( IMIA-NI). The HINZ Nursing Informatics Working Group  is most active of HINZ group.

• NZHUG-New Zealand  Health Level 7 User Group (NZHUG) is the New Zealand arm of international Health Level of 7(HL7) organization,which has a proven  and widely used methodology for standards development. The organization is comprised of  technical committess are directly responsible for  to the organizationthe technical committees are directly responsible for the content of standards. Sigs serves as a test bed for exploring new areas  that may need coverage in Hl 7’spublised standards.
• NZHITC- The NZ Health Cluster Inc. is a consortium of 37 organizations with a common interestin improving health care delivery. The cluster was formed as part of industry New Zealand’s cluster development program and has been formally working together to provide mutual support for local and international business development.
• MoH – the Ministry of Health plays an important role for the formal intra- and intergovernment liaison work it understakes,its influence on sector policy and strategy,and its funding capability.
• DHB’s – District Health Board New Zealand is a national organization that has been set up by 21 DHB’s to assist with representation,help coordinate jointDHB processes  and activities,and undertake work that can be done more effectively  and efficiently on national basis.
• DHB forums- the NZ CIO/CEO/CFO forums comprise members who are chief information officers (CIO’s) chief executive officers( CEO’s) , and chief financial officers (CFO’s) from DHB’s, through sharing information , the forum members aim to advance respective strategies( business and technical).
• HIGB- the health intranet governance  is responsible for the governance of the Health  Intranet,the New Zealand  national health  information network, and has been responsible for the development of the health netwoek code of practice.
• IPAC- Independent Practitioners  Association Council  has a group of key technical people “GEEK” who work within the IPAc and who have established a regular forum to discuss issues and share information. This groups includes some vendors representative.
• HISO – A proactive ministerial committee with responsibility for direction setting together with the  overall governance of the New Zealand health  and disability sector standards agenda.
• Standards NZ- standards NZ are heavily involved in the development and application of national,regional, and international standards many of which are developed in partnership with Australia.
• NZCA-  the New Zealand Coding Authority exists to promote excellence and coding consiensistency in clinical coding through advice and support for the New Zealand  clinical coder workforce and related organization.
• Statistics New Zealand  -( Stats NZ) administers the statistics Act(1975) producing the official  statistics for the nation.
• ACC – The Accident Compensation Corporation  administers New Zealand’s accident compensation Scheme,which provide accident insurance for all New Zealand citizens ,preventing injury ,buying health and disability support services to treat  care for ,and rehabilitate injured people.
• NDPG –  The National Data Policy  Group ,originally the data Definitions Working Group ,was formed to ensure consultation  with the health sector on the data elements that are collected in the national minimum dataset( NMDS) and their definitions. The NDPG in its present form has been existence since 1997 and has been claired by NZHIS staff during that period.
• ILG – Information Liaison Group provides input to the ministry’s current short- term  information projects that are designed to provide DHB’s with access to information from the systems managed by the business units. The ILG has an impact on the decision -making  process of all DHB’s and MoH , in that it is a forum where these parties can be represented when changes to business rules and reporting requirements from the business units can be discussed  and prioritized.
• CLANZ – Clinical Leaders Association  of New Zealand manages issues critical to health  such as clinical safety ,quality of care ,and resource management demands also embracing competent and effective clinical leadership .CLANZ seeks to grasp opportunities evident within  the New Zealand health system for clinicians willing to take responsibility and to show leadership , by building strategic partnerships and alliances with other health organizations and agencies.
• CHECKMATE- Collaboration for Health and Clinical Knowledge Management and Technology  is somewhere unique in being academically led but  having a multisectoral membership including academics ,software developers ,and end users. This group is primarily focused on knowledge  systems rather than technology and the main objective is bring together people from throughout the health IT sector who have interests in research and training.
• HIANZ -  Health Information Association of New Zealand  is involved with medical records and medical libraries.

Health Informatics Groups in Australia

• 

  The history of the formation of medical ,health and NI groupa reflects the difficulties experienced as a consequence of a federal system government and vast distances between population centers.
  Australia has had a representative  to IMIA’s Working  Groups 8 (WG8) now (NI sig) since 1984. Nurses were the second group of health professional to organize themeselves to promote  health informatics in Australia. The general Practitioners were first, beginning in the late 1970’s although the Health Information Managers Association(HIMAA) has been in existence since 1949 but the integration of informatics is more recent. NI is now a Sig of HISA, which came into existence in 1993. It has  been long  and tortourous path to reach this position.
  NI in Australia  began with the Royal Australian Nursing Federation (now ANF) in 1984. A Year later  a small group of midwives in Victoria ,including Joan Edgecumbe,who is now the executive officer of the HISA decide to call a general meeting of nurses in  interested in computer use. About 70 nurses  agreed to establish  the Nursing Computer Group  Victoria( NCGV). This group continued to flourish and hosted the Fourth International Symposium on Nursing use of Computers and Information Science  in Melbourne in 1991. The profits of this conference enabled the formation of the HISA.It has been tortuous path towards the recognition and professionalization of health  (and nursing) informatics as discipline . We have not managed to achieve a unity or consensus regarding how best to operate  as one national professional organization to date although increasingly joint activities are being  organized.

 Historical Development

• NI in Australia  began with the Royal Australian Nursing Federation (now ANF) in 1984. A Year later  a small group of midwives in Victoria ,including Joan Edgecumbe,who is now the executive officer of the HISA decide to call a general meeting of nurses in  interested in computer use. About 70 nurses  agreed to establish  the Nursing Computer Group  Victoria( NCGV). This group continued to flourish and hosted the Fourth International Symposium on Nursing use of Computers and Information Science  in Melbourne in 1991. The profits of this conference enabled the formation of the HISA(Health Informatics Society of Australia).

  

   

Nursing Informatics in Hong Kong

Hong kong nurses established NURSINFO (HK) Ltd. In 1991 ,and this organization has enjoyed a consistent increase in membership. They have as their motto “ Nursing Infomatics for Excellence in  Patient Care” .They  organize regular educational activities,use a communication network,produce a regular newsletter, and are activity involved with the Hong Kong  Society of  Medical Informatics and  the Hong Kong Computer  Society. Together they participate  in the organization of  trade exhibits  and regular conferences. The Hong Kong Hospital  Authority is responsible for over 40 hospitals  and over 50 specialist clinics that are part of a large multisite ,multiprotocol intelligent  data network to provide seamless data communications  . Implementation began in 1993. It includes a clinical management system focusing on patient-oriented data sharing.

This provides longitudinal medical profile for patients and can be accessed  by healthcare  professional 

on a need to know basis. Telemedicine and video conferencing are in use and multimedia enhancement in the clinical setting with voice recording and imaging now helps to speed up the work process and strengthens services in the clinical areas.

Nursing Informatics in South Korea

A  Korea Society of Medical Informatics , the premier organization in Korea dedicated to the development and application of  medical and health  informatics in the support of patient care, education,research and administration of healthcare arena in general. The Society was established in October 1989. KOSMI is hosting the next International Nursing Informatics Symposium to be held in Seoul, August 2006, under the auspices of IMIA NI (http://www.ni.2006.org/).Technology trends The healthcare environment is changing at an ever increasing pace due to the proliferation of new and emerging technologies. Embracing the advances and technology enables us to to deliver healthcare in new and innovative ways. Basic hardware has advanced into multiple components of input and output devices. Development of infrastructures enabled this technology to be networked and internet to provide medium to transmit information nationally and internationally. The physical constraints and boundaries are now so blurred that healthcare delivery can occur at any time or place. New Zealand has been embracing these changes in technology and has particularly benefited from the development of infrastructure. No longer is information restricted to individuals and organization. Higher speed networks including wireless and broadband are enabling information in   a variety of formats to be shared.

Digital images are becoming the norm and picture archiving and communication system(PACS) abound. Eploration into telehealth has occurred in a number of fields  including teledermatology,teleradiology, telepyschiatry, and telepediatrics(Oakley 2001). Improves

transmission in both speed and quality. Improvements in portability are now allowing the use of techonology in a greater range of setting. Both personal digital assistants(PADs) and tablets are being used or trailed in the clinical setting by students and healthcare professionals. One of the nursing schools has issued PADs to its students and the success of this has been evidence by the reluctance of the students to relinquish  them . some Australian nurses are using  PADs for point-of-care information and clinical documentation  for community and acute hospital nursing, hospital based infection control and wound management.

Funding for the use of the  technologies is probably one of the biggest limitations imposed in embracing new technologies to enhance care delivery. Unfortunately for New Zealand ,its size does not allow economies of scale but this does  not prevent efficient use of the available resources. Although the cost for individual items of technology decreases ,our demands for this technology, and therefore our overall spending increases. Nurses need to be prepared to work alongside and use technology to best care for clients. Healthcare organization are now looking to implement clinical information systems and electronic  patient records.

Current National Initiatives 

• The New Zealand Ministry  of Health, in 2001,prepared a 5 –year broad strategic directive for information and technology developments, referred to us  “  The WAVE Report “ that was largely driven and developed by the key stakeholders. 
• The report was produced by means of the collaboration among industry,clinicins,government, and healthcare managers. It identified New Zealand’s most pressing health IT needs and significant issues that will continue to form barriers to improved health outcomes and reducing delivery cost over the next 5 years.
•  The reports has been the cornerstone of formed the foundations for long-term issues such as EHRs. While it is not necessarily unique in its content or conclusions, the collaborative approach to developing the report heralded a new way of getting whole of sector  buy in for a range of national initiatives, changing the focus from debating direction to unifying action. 
• Following WAVE report, the drive for collaboration from the bottom-up has consolidated as the district  health boards(DHBs) replace their isolated departmental systems with more intergraded and dynamics Web-based technologies that support a more connected delivery network.
•  It has also made the development more of a reality. The development of national technology infrastructure has proved useful; however, securing appropriate access to relevant clinical and administrative information throughout the health sector remains the greatest challenge. 
• Early progress has been made in the areas of claims systems and laboratory results. New Zealand government’s health policies have been driving toward a population health management approach.  The national health information agreements and the establishment of the National Health Data Dictionary in 1993 laid the foundation strategic information action plan.
•  Health online was initiated. This was followed by a number of projects initiated by the Australian government: Healthconnect, Mediconnect, the provision of quality health information for consumers known along with more than 360 projects such as the integration of primary health  and hospital care projects, and the establishment of health call centers.

 Standards  Development and Adoption

• Following the 2001 WAVE Report, the minister of health directed that a WAVE working group, the Ministerial Committee on a Health Information Standards Organization (HISO), be established to investigate  the implications of establishing of non statutory organization to manage health information standards.
•  Organizations ,2002. HISO drew together hitherto disperate  health –related groups with specific interest in producing IT standards for New Zealand .
•  HISO’s role includes identifying ,developing,publishing,and monitoring New Zealand’s health information standards( Cressey ,2003). The scope of development activities that HISO will be involved with includes standards associated within the following categorization scheme.

Records structure and content-data formats. 

Vocabulary –codes for medical and other healthcare terms.

Messaging- standards used for the interchange of data.

Security and privacy- how access to information and managed.

• HISO governed by the Health Information Standards Committee-HISC), and supported by the ministry of health produced the New Zealand Draft National Health Standards Information Plan (NZHSP) to assist in its role of developing health information standards for the health  and disability sector. 
• HISO enhances the New Zealand  e- Government Interoperability Framework(e GIF) direction.
• The NZHSP recognizes there is an urgent need to progress work on national standards . It analysis the key sector drivers,requirements,and issues and sets a foundation to  rapidly advance the sector information standards agenda. It proposes a framework for describing the sector priorities,standards development processes,governance and leadership , and presents a clear  statement of the proposed plan for the development and adoption of national health information standards. 
• NZHSP anticipates HISO undertaking the constituent parts of that framework.
• A key driver for HISO’s role- consistent use of standards –is aim at the acceptance throughout the health and health-related industries of such standards. This requires enabling real-time access to information about the standards( i.e., what standards are agreed , what are being developed or proposed ,what initiatives are taking place ,and what are the downstream implications) including where the information may be freely accessed.
•  The availability of detailed  and clinically relevant data is essential for clinical care decisions and for oversight groups making decisions  related to the quality of that care. 
•  Standardized terminology systems are essential to permit the use and exchange of clinical data across applications and IT systems. Given point –of-care documentation ,technology is now available to  build  electronic health information system that will efficiently meet a variety needs. 
• This includes providing immediate feedback to care provides by ,for example,issueing alerts related to relevant best practice guidelines,generating data needed for internal and external  quality monitoring,exchanging critical patient information in a timely manner across the healthcare continuum, and reducing provider burden associated with current documentation requirements.
• Currently one of the most significant challenges to implementing electronic health information system is the current lack of standards for electronic patient medical record information, especially standards around the terminology that expresses clinical documentation.
• Standards New Zealand and HISO,working partnership with standards Australia (SA),were persuaded to establish a health informatics committee in 1992. The SA IT-14 committee now has several active technical subcommittees and works closely with other similar groups such as HL7 Australia, the ISO technical committee 215(TC215) and the committee European de Normalization(CEN) TC251,Nurses are represented via the Royal College of Nursing and Central Queensland University. The focus in Australia has been in the area of standards development to facilitate data interchanged to first of all support all types of ecommerce and now to support the interchange of clinical data. This is putting greater emphasis on the need for a standard architectural structure for patient’s records and terminologies. And number of Australian IT-14 committee and subcommittee as well as Health Level Seven(HL7) Australian members have been instrumental in influencing many international standards to ensure that they meet Australian and New Zealand needs. Particularly the development of new ISO standads for requirements for an EHR architecture  ISO/TS 18308) and the EHR definition,scope and context ISO/DTR 20514(, plus the HL7 EHR System Functional  Model  EHR-S) and the revision of of the four -part CEN/TC 251 EHRcom standard ENV 13606). the latter will now include an additional part detailing the archetype interchange format. archetypes are constraint-based models of domain  entities and were first defined by the Australian-based open EHR group , an international not-for-profit foundation working toward interoperable lifelong EHR's.Two  IT-14 members represent that committee at the national  ICT Standards Committee who report to the NHIG and the AHIC who currently make up the Australian goverment governance model.In July 2004,NHIG endorsed HL7 as the standards for healthcare messaging in Australia.This represents a small step toward the implementation and an increase in the adoption of available standards.