CHAPTER 40: Nursing Informatics in Asia
Objectives:
To describe the development of nursing informatics in selected Asian counties.
To identify historical milestones, changes, and trends influencing how nurses embrace informatics, such as government initiatives and international collaborations.
To discuss NI practice, education, and research.
INTRODUCTION:
Computers were first introduced into the healthcare sectors of Asian counties in the 1970s. 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. This chapter provides an overview of the current status of the field of NI in South Korea, Japan, China, Taiwan, and Thailand. It describes the history of NI, the use of informatics in clinical practice, informatics education, informatics research, and government initiatives and professional outreaches.
The adoption of informatics in Asian countries usually began as a vision by a group of individuals in the government or a professional organization, who promoted the use of information technologies to support nurses in all areas of nursing practice. More and more nursing schools are beginning to realize the importance of providing informatics courses to 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 in NI began to appear in the domestic Asian nursing journals in 1990s. In most countries, information technology first appeared as an educational tool, following by its use in clinical practice in applications such as expert systems and electronic nursing records. This use in clinical practice leads to the development of standards becoming a favorite research topic.
International multidisciplinary informatics links have assisted these beginnings 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 associations in China, Japan, South Korea, Taiwan, and Thailand due to the hosting of triannual 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 for the sharing of experience and knowledge among both experts and users in these three countries.
The chapter concludes by summarizing significant events and examining their impact on the evolution of NI in this region.
KOREA
South Korea comprises 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 23,331 of these, are situated in the Seoul metropolitan area.
History of Nursing Informatics in Korea
The use of computers in South Korean healthcare began in the late 1970s in hospital finance and administration systems to expedite insurance reimbursements. Soon thereafter, the national health insurance system expanded to cover the whole population, and computers became necessary equipment in healthcare organizations. The terms health informatics and NI were first introduced in Korea when the KOSMI was founded in 1987.
In contrast, computers were not used in nursing education and research until 1993, and NI was not taught in universities until 1994. In 1993, the Nursing Informatics Special Interest Group was organized as one of the five special interest groups in the KOSMI, since the Nursing Informatics Group has held its own session at the biannual conferences of the KOSMI.
Further momentum for NI has been coming from funding for a NI study group provided by the Korean Science and Engineering Foundation since 1998.
Korean nurses have attended and participated in many international conferences promoted or supported by IMIA or IMIA-NI since 1989. Korean nurses represented the country at the IMIA-NI Group in 1995.
Use of Information Technology in Clinical Practice
According to report published by the Korea Health Industry Development Institute in 2000, 100% of teaching hospitals, 96% of general hospitals, and 75% of private clinics now have hospital information systems (Korea Health Industry Development Institute, 2000). Korea are using order communication systems (Kwak, 2000), which enable physicians to communicate with other departments for practice-related requisitions and the retrieval of data. In addition, about 95% of teaching hospitals and 20% of general hospitals are equipped with picture archiving and communication system (PACSs). There has been a great deal of interest among healthcare organizations in acquiring these systems since the government announced high reimbursement rates for diagnostic radiology examinations using PACSs in 2000, and PACSs are now one of the most common information technology systems in South Korean Hospitals.
The use of computers in clinical nursing practice in Korea began first in medium-sized hospitals. These hospitals initially used computers mainly for administration and billing, as did most hospitals in other countries, but later a patient-care component was added. These systems allowed physicians to enter medical orders directly into the computer, and major ancillary departments could receive requisitions and enter test results. Nursing information systems proliferated when large hospitals (with more than 1,000 beds) began opening in the mid-1990s. These new hospitals were equipped with nursing information systems when they first opened.
A home healthcare system for community-based clinical practice was developed by the Home Healthcare Team at the College of Nursing, Seoul National University. 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 Informatics Education
According to a recent survey 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 from school to school, and the instructors are mostly self-taught in these subjects. This indicates that there is a need for standardization of health informatics courses for baccalaureate programs based on the task of healthcare professionals, together with graduate programs to produce qualified health informatics educators.
Research
Most papers presented in 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 a tool for nursing education. Distance education using the Internet has also been described.
Another popular research area is the use of artificial intelligence in nursing diagnosis. The use of personalized digital assistants (PDAs) in hospital and home healthcare settings along with the standardization and the use of Web-based electronic patient records are current areas of interest.
Standardized 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.
Administrative information systems in the healthcare sector essentially use the Korean 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 I and II, Nursing Interventions Classification (NIC), Home Healthcare Classification (HHCC), the Omaha system, Nursing Outcomes Classification (NOC), and International Classification for Nursing Practice (INCP), have been translated into Korean and standardized. The NANDA is the most frequently used in nursing education, and the 3N (NANDA-NIC-NOC) and NICP 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 telemedicine, emergency medical systems, infectious diseases reporting systems, and standardization.
The Korean Ministry of Health and Welfare established a long-term plan for a national health and welfare network (NHWN) in 1993. The NHWN covers six areas: public health, hospitals and clinics, health insurance, food and drugs, national pension, and health and welfare administration. The first phase (from 1994 to 1997) computerized the administrative and patient-care activities of health centers. The second phase (from 1998 to 2001) developed infrastructure for the public health network, integrating networks systems among health centers, health sub centers, and primary healthcare posts. An electronic data interchange system 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.
Professional Outreach
Since its foundation in 1987, 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.
Organizations such as the Korean Medical Association and the Korean Nurses Association have also played significant roles by including health informatics in their continuing education programs.
The IMIA has contributed significantly to furthering the knowledge of South Korean healthcare professionals about worldwide trend in health informatics. These individuals have attended and participated in many international conferences promoted or supported by the IMIA since 1989.
Technology Trends
The rapid growth in the number of mobile telephone users (currently estimated to be around 65% of total population) and the advances 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 ate bedsides, but this will soon be extended to other healthcare professionals.
The need for telemedicine continues to grow in Korea with increasing numbers of elderly, patients with chronic diseases, and patients who are discharged early. Many telemedicine systems have been tested over the past 10 years, one of which is a teleconsultation system initiated by the government. Telepractitioners 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.
Summary
The Korean healthcare environment is becoming inhospitable due to high healthcare costs, increasing competitions among healthcare organizations, decreased funding from the government, and customers with more sophisticated demands.
Health informatics and the usage of information technology have seen rapid progress in South Korea. Most of the Korean healthcare organizations were computerized following the introduction of the national health insurance system.
JAPAN
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 about 220,000 nurse’s aides, and there are about 260,000 medical doctors, 90,000 dentists, and 230,000 pharmacists.
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 the monthly salary, and pooled by each insurance union.
The total health expenditure of Japan remains lower than that it some other advanced nations, which is partially attributable to healthier dietary habits. The relatively small number of healthcare professionals working in Japan also helps to contain healthcare expenditure. The average length of hospital stays has recently been shortened, and thus many newly hospitalized patients are in the acute phase.
Health Informatics in Japan
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 the JAMI has held 24 annual and biannual academic conferences, and these conferences have contributed considerably to the progress of health informatics in Japan.
History of nursing informatics in Japan
The Third International Congress on Medical Informatics, MEDINFO18, organized by the IMIA, was held in Tokyo in 1980. This congress included a special interest 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.NI was applied more in clinical practice than in academic fields during the 1990s, with more nurses learning about utilizing computers in nursing practice through the activities of medical information department settings in the national university hospitals.
Nursing Informatics Education
As on April 2004, there were 486 professional schools, 31 junior colleges, 120 universities, and 45 graduate schools in Japan, compared to 461 professional schools, 74 junior colleges, and 30 universities in 1994. This comparison illustrates that nursing education in Japan has shifted from professional schools to universities and postgraduate education during the last 10 years. Continuous education of NI is being emphasized, along with the promotion of electronic health record.
Nursing Informatics Research
The amount of NI research is increasing in Japan, the two main purposes of which are improving the quality and standardization of nursing practice. There were many reports on research into the use of information technology as an educational tool during the 1990s and on the use of information technology in clinical practice, especially on decision support systems for nursing in hospital information systems and electronic health records.
Nursing Informatics Research
Becoming a specialist in NI is useful when hospital information systems and electronic health records are introduced. The accreditation program of the Japan Nursing Association does not recognize the training for such specialists. 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.
Japanese Government Initiatives and Standards Development in Japan
The standardization of medical information is one of the main themes in the healthcare sector. 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. This is especially useful for hospitals introducing hospital information systems for the first time. 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.
CHINA
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 influenced by healthcare services in rural areas. The primary healthcare systems in rural China typically involve cooperation at country, town, and village levels.
The SARS epidemic in China leads to reconsiderations of the current healthcare systems in rural areas. Some Chinese consider that the system is not moving forward and that more effect should be devoted to epidemic prevention, and that a new system of cooperative medical care and new salvation system of the poor should be up to ensure health in rural areas and enhance the stability of society and economic development of the country.
The China Medical Informatics Association (CMIA) was founded in 1981. The Chinese Society of Medical Information was founded in 1993, and it's activities include holding academic conferences and seminars, continuing education, and training
The Hospital Information Management Association was founded in 1996, and it's activities include holding national and international academic collaborations and exchanges, establishing rules and standards of national hospital management, and training hospital information management staff.
Nursing Information Systems in China
The development of nursing information management systems began in China late 1970s, and they were first used in 1987. The first software implementation was a computer-assisted primary nursing care system. Many hospitals in China now use nursing information systems, although there are no official statistics available. Some examples include a nursing information system for the management of nursing staff, nursing operation work, continuing education, scientific research, and finance and economics.
History of Nursing Informatics in China
The Nursing Informatics Special Interest Group with 20 hospitals nurses was founded as a branch of the CMIA in 1991. Te first article referring to the term "nursing information 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. The term NI was first used in the Chinese literature in 2002.
Nursing Informatics Education
Higher nursing education was 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.
According to the literature review, computer-assisted instruction began at nursing institutes in China during the mid-1990s, since then it has been used in baccalaureate and continuing education courses in the clinical nursing field. Distance learning is also being used for nursing continuing education in China. The first distance learning program in China is a collaborative between China and Canada run by the School of Nursing, Tianjin Medical University in 1999.
Nursing Informatics Research
NI research is at its infancy in China, with only 30 research articles published in domestic nursing journals from 1994 to 2004 (with 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 use of NI in clinical practice in China includes nursing quality management, and training clinical skills for staff nurses.
The major weakness of nursing information management systems in China is the lack of national standards and the low level of computer literacy and informatics skill exhibited by nurses.
THAILAND
The country has a population of about 65 million living in 76 provinces. The government is currently launching a Universal Healthcare Coverage policy in order to improve the access to and quality of healthcare, as well as to contain healthcare expenditure. These policies require changes in human resources including nurses, since the demand for nurses in primary care settings 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 WHO, and the Ministry PH.
The Development of a Health Information System
In 1997, the Thai MOPH began to implement a national health information system, which included the development of a nursing component. Funding was received from the WHO 1999 as a result of a collaborative effort between the Center for Nursing research at the Department of Nursing, The Faculty of Medicine, Mahibol University, and the MOPH Nursing Division to develop the ideal nursing minimum data set and a preliminary nursing classification system.
Development of an NMDS
The first step in developing a nursing information system is to identify an essential NMDS, and here the process of developing an NMDS specific to Thailand is discussed. That survey study identified 23 items of nursing data, including patient name, hospital number, ID number, admission number, patient address and phone number, address and phone number of significant person, gender, birthrate, religion ,education, health insurance, patient and family medical history/allergy, admission date, medical diagnosis, laboratory test, nursing problem, using intervention, nursing outcome, discharge/expired date, discharge plan, condition before discharge, referral, and home visit.
INCP Translation and Validation
The Nurse's Association in Thailand, the development of the ICNP and agreed to translate into Thai and validate an alpha version thereof.
The first NI conference was held in Bangkok in 1999, supported by the WHO. More than 200 nurses across the country were invited to validate and comment on the alpha version of the translated ICNP. Later in October 1999, the translation of the beta version of the ICNP was completed, validated, and disseminated. However, many issues , such as the need concept-based translation and increasing nursing involvement in the process, still need to be addressed in order to implement the date set successfully.
Nursing Information System
A further attempt to implement the ICNP in the Thai nursing environment was the developed, a collaborative software program called "Healthcare 2000" by the MOPH Nursing Division for the collection and retrieval of nursing care data.
Although a preliminary Thai NMDS has been identified, challenges associated with its development and implementation within the Thai national health information system remains.
Professional Outreach
The main objectives of TMI (Thai Medical Informatics Society, 2003) are as follows:
To be the center for coordinating and distributing medical information.
To develop means for the management of medical information in administration and academic areas.
To exchange information and experience in medical informatics.
To support those who practice medical informatics.
To provide suggestions and recommendations for medical information sectors both within and outside the MOPH.
To not be involved in any commercial or political activities
The main activities of TMI are as follows:
Holding an annual conference
Supporting the meeting, training, and information sharing for the development of medical informatics in Thailand
Publishing and distributing four issues of documents per year as approved by the board
Being the center for the coordination and ideas focused on the development of medical informatics
The TMI includes a clinical informatics special interest group, a NI special interest group, and the HIS/LIS Club. The NI interest group focuses on the classification of nursing data and the development in nursing databases. The TNI supports the development of NI, especially nursing databases using the ICNP.
The activities of TNI are as follows:
Holding a joint annual meeting with the Nurses' Association of Thailand and the Medical Informatics Society
Publishing and distributing its newsletter every 4 months
Supporting other academic and research activities in NI
Responding to the NI training needs of Thai nurses
Standards Development
The development of Thai nursing standards is related to the development of the ICNP, although for medicine the ICD 10 has been used in all health service facilities. The HL7 has been employed in many hospitals as the standard interface for the Web-based hospital information systems.
TAIWAN
There were 610 hospitals and 175,000 healthcare professionals in Taiwan 2002, serving a population of 22.5 million. The healthcare professional includes 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. Computers had been used in nursing education since the 1980s, and the related nursing research into patient classification supported by National Science Council began in the 1990s. Although a formal master's program focusing on NI was not available until 2001, the elective courses in baccalaureate and master’s programs have started in the late 1990s.
Nursing Information Systems in Taiwan
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 Education
Computer-assisted instruction programs have been developed by the Ministry of Education for nursing vocational education programs since 1986. The growth of the internet has lead to the integration of distance education into nursing curricula. Online courses are available for baccalaureate programs in counseling, teaching principles and strategies, and long term care.
Nursing Informatics Research
NI research is still at its infancy in Taiwan, with only around 40 papers published in domestic nursing journals in the period 1994-2003. The first formal academic association on NI was set up in 2004, when a NI working group was organized within the Taiwan Association of Medical Informatics, which had been established in 1991.
Standardized terminology such as existing nursing diagnosis classification systems and the ICNP has been translated for clinical use, and tests of their reliability and validity have been proposed in Taiwan.
Nursing Informatics Practice
Computerized care plans are now common in clinical use. Moreover, decision support systems to test the integration of medical diagnoses and nursing diagnoses, and expert systems implemented on PDAs for the emergency triage system have been reported. PDA has been used recently by nurses in their daily practice.
Standardization and the National Health Information Infrastructure
The ROC Biological and Medical Engineering Association and the Taiwan Association of Medical Informatics successfully obtained approvals from the international DICOM and HL7 organizations to become the members in 2000.
A national "e-Taiwan" program has been promoted by the ministry of Health to promote the development of health informatics in Taiwan since 2002.
