Information systems in hospitals - Semantic Scholar

Int. J. Networking and Virtual Organisations, Vol. 13, No. 1, 2013

Information systems in hospitals: a review article from a nursing management perspective Laura-Maria Murtola*, Heljä Lundgrén-Laine and Sanna Salanterä Department of Nursing Science, University of Turku, 20014-University of Turku, Finland and Hospital District of Southwest Finland, 20500 Turku, Finland E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] *Corresponding author Abstract: Information management in hospitals is challenging due to vast amounts of information and a great number of people participating in the organisational functions. Information management plays an important role in the provision of care and it can be improved by information and communication technology. The purpose of this literature review is to describe what information and communication systems are available for nurse managers in hospitals to support their decision-making. Managerial decision-making occurs on strategic, tactical and operational levels. The main findings are that several different information and communication systems have been developed to support nurse managers’ information management, however, these systems mostly focus on strategic and tactical decision-making levels without real-time information support, and furthermore, operational decision-making is weakly supported. Also, research evaluating how the existing systems support nurse managers’ decision-making is lacking. Keywords: nursing; management; decision-making; information systems; hospital. Reference to this paper should be made as follows: Murtola, L-M., Lundgrén-Laine, H. and Salanterä, S. (2013) ‘Information systems in hospitals: a review article from a nursing management perspective’, Int. J. Networking and Virtual Organisations, Vol. 13, No. 1, pp.81–100. Biographical notes: Laura-Maria Murtola is a PhD student at the Department of Nursing Science at the University of Turku. Her research interests are health service research, decision-making and intensive care nursing. She is a participant of the IKITIK consortium, which works with the analysis of electronic health documentation and decision support systems for clinicians. Heljä Lundgrén-Laine received her PhD in Nursing Science at the University of Turku. Her research areas include health service research, intensive care nursing and decision-making. She is the author of several research papers in national and international scientific journals. She is a participant of the IKITIK consortium, which works with the analysis of electronic health documentation and decision support systems for clinicians. Copyright © 2013 Inderscience Enterprises Ltd.

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L-M. Murtola et al. Sanna Salanterä received her PhD in Nursing Science at the University of Turku. She is a Professor of Clinical Nursing Science at the University of Turku. Her areas of expertise include health technology, health service research and decision-making. She has several national and international research projects and has published over 200 research articles in national and international scientific journals. She is a participant of the IKITIK consortium, which works with the analysis of electronic health documentation and decision support systems for clinicians. This paper is a revised and expanded version of a paper entitled ‘Governance of managerial information needed by nurse managers in hospitals – a literature review’ presented at the Proceedings of the 4th International Conference on Well-Being in the Information Society, WIS 2012, Turku, Finland, August 2012.

1

Introduction

Hospitals are organisations where healthcare professionals provide complex care using specialised knowledge and equipment to meet patients’ care needs. Conventionally, hospitals comprise different clinical departments and functional units (Aas, 1997) where care provision is a collaborative task including professionals from medicine, nursing and allied health, and services regarding administration, rehabilitation, diagnostics, nutrition, maintenance and other patient support services (Sultz and Young, 2011). Hospitals can be described by using Weber’s (1978) thoughts on bureaucracy where authority, command and power are central concepts. Hospitals typically have a hierarchical structure with clearly defined roles and regulations. The distribution of power and authority depends on the placement in the hierarchy, and responsibilities are well defined for all members (Mintzberg, 2002; Virtanen and Kovalainen, 2006). Traditionally, hospitals have a functional design, but also divisional and matrix designs are used (Creteur and Pochet, 2002) however, currently, there is a trend of change from functional designs towards more flat ones (Aas, 1997). There have been attempts to connect organisational design with outcomes, effectiveness and efficiency (Creteur et al., 2003) and process-based organisations have been shown to improve hospital efficiency (Antonio and Ludwig, 2007). Regardless of the organisational design, much information is produced and processed to support care delivery in hospitals. In addition to administrative data, information is produced during each patient’s treatment period from all phases of the process: scheduling, pre-admission, admission, treatment and discharge (Wager et al., 2005). Information management in hospitals is challenging due to the large number of participants and units, complex processes and various information systems involved. To date, more and more of these systems are computerised. Systematic information management and improvements in information and communication technology increase the quality of care and reduce costs (Hillestad and Bigelow, 2005; Winter et al., 2011). Various information systems have been developed to improve information management and support organisational functions. There are laboratory, pharmacy and radiology systems; clinical data repository (CDR) systems; computerised provider order entry (CPOE) systems; nursing/clinical documentation

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systems; clinical decision support systems (CDSS) and picture archiving and communication systems (PACS) (Springmann, 2012). But information management and information system development in healthcare organisations is still recognised as an area in need of improvement (Haux, 2006). Organisational design, information management and technology are all important factors in improving the quality of healthcare in the future (Glickman et al., 2007). Information is needed in managerial decision-making when organisational goals are accomplished through planning, execution and control (Thompson and Cats-Baril, 2003). This information is commonly scattered in different systems and furthermore, managers may also receive inaccurate or unreliable information. Information management problems are caused by several factors. Firstly, most clinical information systems are developed to support only one specific clinical task, such as diagnostics or administration of medicines, and there are typically challenges in the communication between these different systems (Cantrill, 2010; Springmann, 2012). Secondly, large amounts of information lead to an information overload (Wilson, 2001). Reasons for information overload in healthcare settings are according to Hall and Walton (2004): 1

the increasing information availability

2

the new and fast information and communication technologies

3

the changed nature of work that is becoming multi-professional

4

the end users’ active part in the pursuit of information.

But, information overload might also depend on the ability to interpret information, instead of the amount of information (Sutcliffe and Weick, 2008). Information technology can be used to reduce information overload and to support managerial decision-making (Thompson and Cats-Baril, 2003). Thirdly, there might be difficulties managing or obtaining necessary information for decision-making (Hall and Walton, 2004; Kontio et al., 2013). The development of information systems for hospital use is challenging due to content demands concerning complex environmental and functional issues, ethical and legal issues concerning e.g., privacy, and technical issues due to the proliferation of non-integrative information systems (Cantrill, 2010). Decision makers’ information needs in hospitals depend on the organisational placement and area of responsibility, which vary depending on the organisational design. The information needs on different levels in the hospital vary correspondingly (Lin et al., 2007). Nursing management is divided into upper-, middle- and frontline management, all of which have different responsibilities (Lin et al., 2007; Sullivan and Garland, 2010). Their information needs typically concern patient care, available resources, administration and management (Winter et al., 2011; Kivinen and Lammintakanen, 2013). The upper management is generally interested in information about the quality of care and the costs of services whilst clinical personnel, e.g., physicians, staff nurses and allied health, are interested in patient information for care related decisions. However, middle managers need information about care processes and human and material resources (Kontio et al., 2011; Lundgrén-Laine et al., 2011). Also information needs between different professionals on the same level in the organisation differ. For example, physicians’ information needs in intensive care coordination concern more direct patient

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care when compared to charge nurses’ information needs, which are more varied and concern mostly organisational issues and staffing (Lundgrén-Laine et al., 2013). Generally, information systems can support managerial decision-making in different ways through access to data, tools for data manipulation, reporting, documentation, communication, statistical analysis and decision support. Information systems are developed to control operations (management information systems), automate highly structured decisions (automatic payroll deposit), support complex unstructured decisions (decision support systems), augment knowledge (expert systems), improve knowledge management (organisational learning), and support strategic planning (executive support systems) (Thompson and Cats-Baril, 2003). Information systems are also developed for communication between professionals in the hospital. For example, physical information spaces are developed to support daily care coordination in units where changes in schedules commonly occur, such as surgery departments, but these still have physical barriers in supporting care coordination (Scupelli et al., 2009).

2

Theoretical framework

Managerial decision-making occurs on three levels in the hospital. These are strategic, tactical and operational levels (Winter et al., 2001, 2011; Kontio et al., 2013). Strategic level decision-making concerns organisational long-term goals such as mission and vision. Tactical level decision-making concerns organisational short-term goals, such as the distribution of resources or practices and operational level decision-making concerns daily activities. The main functions in the hospitals are executed through care coordination, which requires decision-making on different levels and across units in the organisation. This compels much information to be exchanged. The goal of care coordination is to get the right resources to the right place at the right time to meet the right patients’ care needs. Nyssen (2007) divides coordination into three types: vertical coordination, lateral coordination and longitudinal coordination. 1

Vertical coordination concerns decision-making responsibilities and information on different levels in the hierarchy. These responsibilities depend on placement in the organisation, as professionals in different positions have access to different information (e.g., workload information).

2

Lateral coordination covers different areas in the hospital that obtain information, which is combined into a broader base of knowledge (e.g., knowledge management).

3

Longitudinal coordination refers to all activities that concern the patient, characterised by continuously changing information (e.g., clinical management).

Here, the focus is on information management from a nursing management perspective and therefore, it is more suitable to talk about management of different types of information instead of using the concept care coordination. Information management occurs on strategic, tactical and operational levels and the levels are interconnected as described by the vertical arrows in Figure 1. Nursing management accounts for the enabling of high quality, effective and efficient nursing through leadership functions such as, organisational strategy development, provision of adequate human and material resources, ensuring staff competence,


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development of nursing care, and budgeting (Ministry of Social Affairs and Health, 2009). The goal of managerial decision-making in nursing is to provide optimal patient care with minimal costs. Most nurse managers make decisions on tactical and operational levels in the hospital. This decision-making is often characterised by information needed immediately to coordinate the nursing activities. Figure 1

A descriptive model of decision-making levels and information management in hospitals (see online version for colours)

The nurse managers’ lateral information management in operational decision-making concerns e.g., patient transfers between different departments in the hospital. Longitudinal information management in operational decision-making concerns, for example, the assignment of patients to nurses during a shift based on care needs. Information regarding resources used and patient care needs on the operational level is generally used in planning future allocation of resources. Lateral information management in tactical decision-making concerns, for instance, decisions about practices, such as workforce allocation between units during vacations or peak seasons. Longitudinal information management in tactical decision-making concerns for example, ensuring staff competencies through systematic education and monitored training programmes. Lateral information management in strategic decision-making concerns e.g., organisational development based on caring needs. Longitudinal information management in strategic decision-making concerns, for example, organisational values such as patient oriented care. All types of information management and decision-making on all levels in the organisation are interconnected. A strategic decision concerning e.g., budget cuts is communicated vertically to all parts involved top-down or bottom-up in the hierarchy as the decision has an impact on both tactical and operational levels. Similarly,

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information is communicated to tactical and strategic levels if patient care needs on the operational level change, which might lead to changes in resource allocation in or between units. Nurse managers’ decision-making processes are complex and they use different decision-making strategies (Effken et al., 2010). Nurse managers receive much information and their need for decision support tools has been notified. They use different information systems to get the information they need and the absence of integration between these systems is a typical problem (Effken et al., 2011). Different computer-based decision support tools exist to support decision-making about the adequacy of resources. These tools integrate clinical and financial information with unit activity and staffing patterns. However, nurse managers also need other sources of information to explain patterns the decision support systems are not able to explain, and furthermore, the different information systems might be difficult to use (Diers et al., 2000). Information systems in hospitals have been developed for multi-professional use, but systems developed to support nurse managers’ decision-making are still few. There are obvious information management challenges as the creation of manual information tools necessary for the support of decision-making when coordinating care, may take up to 50 minutes during each shift (Gurses et al., 2009). The purpose of this literature review is to describe what information and communication systems are available for nurse managers in hospitals to support their decision-making. The research questions are: 1

What information and communication systems are available for nurse managers?

2

For what purpose are these systems developed?

3

Methods

A literature review was conducted to explore information and communication systems available for nurse managers in hospitals. Different databases were searched (CINAHL, PubMed (MEDLINE), ABI/INFORM Global, IEE Xplore and Cochrane Database of Systematic Reviews) with different combinations of the following search words: management information systems, hospital, coordination, technology, nurse manager and nursing. The medical subject headings (MeSH) database, which is a NLM controlled vocabulary thesaurus for indexing articles for PubMed, was used to refine key words in the search. The database searches were conducted in the spring of 2012. A manual search was also conducted on the basis of findings in the database searches. The database searches are described in more detail in Table 1. Inclusion criteria for the chosen articles were: scholarly journal publications about information systems that nurse managers or nurses in charge of care coordination use in hospitals. Articles concerning healthcare organisational decision-making on a general level and clinical decision-making concerning direct patient care such as bedside nursing were excluded. Articles included were reports of studies, or writings by specialists in the field. The findings were categorised using the model of decision-making levels and information management in hospitals presented in Figure 1, based on the descriptions of the information systems in the articles.

Information systems in hospitals Table 1

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Search words used and results of the database searches

Database PubMed MEDLINE

CINAHL EBSCO ABI/INFORM Global ProQuest

IEEE Xplore ProQuest Cochrane Database of Systematic Reviews

Search words

Results

Management information systems AND hospital AND coordination AND technology

41

Management information systems AND hospital AND nurse manager AND technology

32

Management information systems AND hospital AND nurse manager AND technology AND coordination

0


9

Management information systems AND hospital AND nursing

37

Management information systems AND hospital AND coordination AND technology*

36

Management information systems AND hospital AND coordination AND technology AND nurse manager*

1

Management information systems AND hospital AND nurse manager*

21

Management information systems AND hospital AND coordination AND technology**

3

Management information systems AND hospital AND nursing**

5


0

Management information systems AND hospital AND nurse manager AND technology

0

Management information systems AND hospital AND nursing In total

2 187

Notes: *limited to scholarly journals, **limited to journals

4

Results

The database search resulted in 187 articles and one article found by manual search. In this literature review 25 articles were included. Articles were excluded for the following reasons: not in English (5), not about hospitals (27), not about nursing management (41), not focusing on information systems (20), direct clinical management or care (43), not accessible articles (7) and duplicate of already included articles (20). The selection process of the included articles is described in Figure 2. Overall, 72% of the articles included in the literature review were from the USA (n = 18), but articles were also from the UK (n = 3), Finland (n = 2), Canada (n = 1) and Denmark (n = 1). The articles were published between 1987 and 2011. The number of the publications was on the increase, with two articles published between 1980 and 1990, eight articles published between 1990 and 2000, and fifteen articles published between 2000 and 2011. Altogether 60% (n = 15) of the articles were descriptive writings by specialists in the field, which were based on local developmental projects or professional experience. The remaining 40% (n = 10) reported implementing information systems in

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practice and only 24% (n = 6) were evaluating these information systems. A more detailed description of articles found in the literature review is presented in the Appendix. Figure 2

Flowchart of the selection of articles included in the literature review (see online version for colours)

The literature review revealed that different information systems are available for nurse managers in hospitals. The data analysis proceeded in three steps. Firstly, the types and purposes of available information systems were identified, secondly, the information obtained for these information systems was examined, and thirdly, the information systems were categorised by using the model of decision-making levels and information management in hospitals presented in Figure 1. Four types of information systems available for nurse managers were identified. These were developed for: 1

performance evaluation and planning

2

workload measurement and resource allocation

3

shift management

4

communication.

The information systems available for performance evaluation and planning were diverse and they integrated several kinds of information. Information systems could store, retrieve, analyse and compare data by combining clinical, operational and financial data (Waldo, 1999). One nursing performance information system was based on information about staffing, work environment, unit performance and evaluations (Gregory, 1995). Another information system called the ‘six-pack-tool’ combined information about department volumes, costs, patient satisfaction, hours per patient day, turnovers and human resources (Mays et al., 2008). A third information system, the nursing


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management minimum dataset, was based on environmental, nursing and financial resources (Simpson, 1997). Furthermore, nurse managers could build their own databases for information management concerning e.g., analysis of resource allocation, staff education and reporting (Tamarisk, 1990), or use the data warehouse method to provide information about patients, care processes and financial perspectives (Junttila et al., 2007). The information systems that were available for workload measurement and resource allocation were based on patient acuity information or patient classification information (Fralic, 1989; Diers and Bozzo, 1997; Brown, 1999; Botter, 2000), which could be in combination with nursing information (Trundle et al., 2001; Walsh, 2003; Claudio, 2004), or furthermore, in combination with information about processes (Fabray and Luck, 2000). These systems were intended to support performance evaluation, planning and budgeting. However, few information systems could be used to support the daily decision-making with real-time information. One simulation-based patient acuity information system supported assignments of patients to nurses by tracking the nurse’s workflow, but this system did not support assignment of new patients to the unit (Sundaramoorthi et al., 2010). Another system provided patient information almost real-time and could be used to allocate nurses to the next shift, to improving quality of care and to support the staff (LaBranche, 2011). The information systems that were available for shift management were hospital-wide and based on open shifts issued to nurses by a nurse manager or coordinator (Vautier et al., 2003; Bantle, 2007; Valentine et al., 2008). Nurses could access information about the shifts over the Internet at home or at the hospital and sign up for excess shifts in the area that they were qualified to work in. These systems combined information on nursing resource needs in different areas and nurses’ competencies and skills. The information systems that were available for communication consisted of different kinds of systems and technologies. Information boards were available for communication between different professionals and different areas concerning clinical information from admission to discharge or information on the general situation in the unit (Wong et al., 2009; Hansen and Bardram, 2007). Local area networks were installed to improve information retrieval, decrease time to access information and enable communication over the Internet to improve productivity (Grinde, 1994). Traditional means of communication such as phones (Vautier et al., 2003; Hansen and Bardram, 2007) and e-mail were also available, and a web page was developed for the communication of hospital availability to the emergency medical services. Shared drives and web pages were also available for educational purposes. Computerised patient tracking systems were developed for the communicating of patient transfers (Vautier et al., 2003) and for the tracking of clinicians (Hansen and Bardram, 2007). Several articles reported dissatisfaction with existing information and communication systems. One article discussed electronic information systems available for nurse managers developed for human resource management, financial management, clinical management and communication. However, nurse managers did not experience that these information systems supported their decision-making sufficiently, in particular, more information about human resources and outcomes evaluation was wished for, and furthermore, these information systems could be difficult to use (Lammintakanen et al., 2010). Another article reported nurse managers’ dissatisfaction with a computerised nursing information system, which combined clinical information with workload

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information and financial information to improve the management of nursing resources and finance (Malone et al., 1997). This system did not support nurse managers’ information needs and was not cost-effective and therefore removed from use. A third article evaluating a decision support system’s effect on ward nurses’ decision-making when coordinating care, showed that all professionals involved must be engaged in the system’s use for the system to function properly (Fabray and Luck, 2000). A fourth descriptive article stated that patient classification tools did not support nurse managers’ information needs and that hospital systems should be integrated and built around one database, so that data entry and data retrieval could be easily accessible, and additionally, that filtering criteria for different professionals was needed (Mowry and Korpman, 1987). A comprehensive information system like this might be able to calculate patient acuity and staffing patterns, retrieve human resource and material costs, automate supply inventory on the basis of usage, provide management reports on query, evaluate performance, facilitate productivity measurements and improve monitoring (Mowry and Korpman, 1987). Information systems were specifically developed for nursing management (Mowry and Korpman, 1987; Fralic, 1989; Gregory, 1995; Diers and Bozzo, 1997; Malone et al., 1997; Simpson, 1997; Brown, 1999; Waldo, 1999; Botter, 2000; Walsh, 2003; Claudio, 2004; Bantle, 2007; Junttila et al., 2007; Mays et al., 2008; Valentine et al., 2008; Sundaramoorthi et al., 2010) or available for different professionals such as medical staff and allied health (Trundle et al., 2001; Hansen and Bardram, 2007; Valentine et al., 2008; Wong et al., 2009; Lammintakanen et al., 2010). Some systems were built on information obtained from one source as others integrated information from several sources (Mowry and Korpman, 1987; Gregory, 1995; Malone et al., 1997; Simpson, 1997; Waldo, 1999; Botter, 2000; Vautier et al., 2003; Walsh, 2003; Claudio, 2004; Mays et al., 2008). Evaluations of information systems developed for nurse managers were poorly reported. The few studies found evaluating these systems usually focused on the usability of a system through interviews and questionnaires (Hansen and Bardram, 2007; Junttila et al., 2007; Sundaramoorthi et al., 2010). Only two studies evaluated the effectiveness of the system with other methods (Malone et al., 1997; Wong et al., 2009). An outline of the information systems found in the literature review that nurse managers’ use is presented in Table 2. There are many different information and communication systems that have been developed for one decision-making level in the hospital to support vertical, lateral and longitudinal information management. In addition, there are information systems that have been developed to support decision-making on several levels e.g., patient acuity systems that can be used in tactical decision-making when planning the use of the nursing resources in the near future, as well as in strategic decision-making when analysing costs and planning budgets (Botter, 2000). A large number of the information systems were developed to support strategic and tactical decision-making, based on information concerning nursing and patients, in particular for planning and performance evaluation. However, information and communication systems developed to support nurse managers’ operational level decision-making were scarce.

Information systems in hospitals Table 2

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Outline of contemporary information and communication systems available for nurse managers’ decision-making on different levels in hospitals

Information systems

Strategic decision-making

Tactical decision-making

Operational decision-making

Ve

Ve

Ve

Automated hospital information systems (Mowry and Korpman, 1987)

La

Lo

X

X

Automated open shift management (Valentine et al., 2008)

Lo

X

X

La

Lo

X

Automated staffing and scheduling systems for planning and budgeting (Vautier et al., 2003) Automated workload measurement system (Walsh, 2003)

La

X

X

X

X

X

X

X

X

X

X

X

X

X

Clinical dashboard for daily performance evaluation (LaBranche, 2011) Integration of nursing and hospital resource information (Diers and Bozzo, 1997)

X

X

X

Communication device: phone (Vautier et al., 2003; Hansen and Bardram, 2007)

X

Communication device: e-mail (Vautier et al., 2003)

X

X

Communication device: shared drives (Vautier et al., 2003)

X

X

X

Communication device: web page (Vautier et al., 2003)

X

X

X

X

X

X

X

X

Communication devices: patient tracking system (Vautier et al., 2003)

X

X X

X

X

Communication device: information board (Hansen and Bardram, 2007; Wong et al., 2009)

X

X

Computerised operating room board (Vautier et al., 2003)

X

X

Database management system (Tamarisk, 1990)

X

Local area network (Grinde, 1994)

X

X

X

X

X

X

X

X

X

Nursing information system (Malone et al., 1997)

X

X

X

X

Nursing management information system (Junttila et al., 2007)

X

X

X

X

Notes: Ve = vertical information management, La = lateral information management, Lo = longitudinal information management.

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Table 2

Outline of contemporary information and communication systems available for nurse managers’ decision-making on different levels in hospitals (continued)

Information systems

Strategic decision-making

Tactical decision-making

Operational decision-making

Ve

Ve

Ve

Nursing management minimum dataset (Simpson, 1997) Nursing performance information system (Gregory, 1995)

X

La

Lo

X

X

X

X

X

Online booking systems and class requests (Vautier et al., 2003) Patient acuity system (Claudio, 2004)

X

Patient acuity system (Brown, 1999) Patient classification system (Botter, 2000)

X

X

X

X

X

X

X

X

X

La

Lo

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Patient classification system (Fralic, 1989) Performance evaluation information systems (Waldo, 1999)

X

X

X

La

Lo

X

Patient tracking status board (Vautier et al., 2003)

X

X

Tracking system of clinicians (Hansen and Bardram, 2007)

X

X

Ward management system (Fabray and Luck, 2000)

X

X

Six-pack tool (Mays et al., 2008)

X

X

X

X

Workforce planning (Bantle, 2007) Workload measurement tool (Trundle et al., 2001) Simulation-based patient to nurse assignment system (Sundaramoorthi et al., 2010)

X

X

X X

X

X

X

X X X

X

Notes: Ve = vertical information management, La = lateral information management, Lo = longitudinal information management.

5

Conclusions

The purpose of this literature review was to describe what information and communication systems are available for nurse managers in hospitals to support their decision-making. The literature review revealed many information and communication systems that have been developed for nurse managers to support different managerial functions, such as planning, evaluating, organising, controlling and reporting, on different


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decision-making levels in the organisation. None of the information and communication system was found to support information management on all decision-making levels. The reported information systems were developed for different purposes and most were developed for performance evaluation, workload measurement, shift management and communication. The information systems could be categorised using the model of decision-making levels and information management in hospitals presented in Figure 1. Different information and communication systems were available for all decision-making levels in the hospital to support vertical, lateral and longitudinal information management. However, systems were not developed for information management and decision-making levels in an even way as the majority of the information systems found were developed for strategic and tactical decision-making levels. Several information systems gathered information from a number of sources but the systems were mostly collecting data retrospectively for evaluation of performance of nursing, finance and quality, and therefore the systems did not support decision-making with real-time information. Most nursing management work in hospitals occurs on tactical and operational levels regardless of the organisational design, but only a few information and communication systems identified were developed for operational decision-making. These systems gathered patient and nursing information and were developed for the allocation of staff. One simulation-based nurse activity tracking information system was developed to support daily decision-making with real-time information; however, this system did not function with new patients on the ward (Sundaramoorthi et al., 2010). Another system was developed to support decision-making when coordinating care on a ward, but there were implementation problems due to other professionals that did not engage in using the system (Fabray and Luck, 2000). Other systems available in operational decision-making were developed for communication between professionals (Vautier et al., 2003; Hansen and Bardram, 2007; Wong et al., 2009). In spite the number of information systems developed to support nursing management, nurse managers reported that existing information systems did not support their decision-making sufficiently (Mowry et al., 1987; Malone et al., 1997; Lammintakanen et al., 2010), and furthermore, that these systems might be difficult to use (Lammintakanen et al., 2010). Nurse managers’ decision-making occurs often in situations where decisions must be made without delay, and based on the findings in this literature review it seems that operational decision-making is weakly supported by information systems and real-time information. This finding is supported by an earlier study (Effken et al., 2011). Evaluative research concerning different information and communication systems were scarce. Evaluation was often based on usability and explored through surveys and interviews. Furthermore, research reporting efficiency and effectiveness of information systems in patient care was lacking. In addition, information needed for decision-making seems to be scattered in different systems and the influence of information systems on end-users’ decision-making has not been sufficiently studied. The information systems available in hospitals are usually developed to serve a specific purpose. This starting point makes the system rigid, hence lacking flexibility to support different professionals’ information needs. As a result decision makers need to search for information from several sources, which is time consuming and ineffective. Information systems should provide information of the whole care process in order to

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support decision makers in successful care coordination within and between hospital units (Kontio et al., 2011). Furthermore, the information systems that have been developed seem to be difficult to use (Diers et al., 2000; Lammintakanen et al., 2010). Information systems should be flexible so that they can be modified situation specifically on the basis of user needs depending on the level and professional role to support information needs and decision-making in care coordination. Information systems that integrate information from several sources, with easily accessible data entry and data retrieval possibilities for different professionals with divergent information needs could be used to support many managerial functions (Mowry and Korpman, 1987). The reliability of the result of this literature review depends on the search words used in the database searches and the quality of the articles included in the review. The MeSH database was used to find the appropriate search terms. In the future search words such as information management, evaluation and nursing administration could be beneficial to include into the array of search words to find more articles. The search resulted in 188 articles, of which only 8 articles reported studies in practice. Hence, writings by specialists were also included in the literature review. The articles written by specialists were usually based on experiences of information systems and some of them, were written on a general level, not explaining in detail the implementation of a specific information system. Descriptive articles would not have been necessary to include in the review had there been high quality research reports to use. In conclusion, research on information systems developed to support nurse managers’ decision-making in hospitals seems to be scarce. A growing amount of information needed in care coordination creates a demand for flexible information management tools that assist decision makers on different levels and in different professions. A comprehensive understanding of the subject would create a basis for further development and improvement of information systems and also support nurse managers when they are coordinating care. It seems that research in this area is on the increase, based on the publication years of the articles in the review. But still a discrepancy exists between the information systems needed by nurse managers and the existing ones. One possible explanation for this is that nurse managers might not have been able to communicate their needs. Also, how different information systems support nurse managers’ decision-making and perspectives of effectiveness and efficiency in patient care need to be studied further. User-oriented research that focuses on usability is needed in order to develop information systems that are user-friendly and cost-effective. More research should also be focused on how information systems should be developed to support nurse managers’ operational level decision-making.

Acknowledgements An earlier version of this article was published in WIS 2012 conference proceedings: Eriksson-Backa, Kristina – Luoma, Annika – Krook, Erica (Editors), Exploring the Abyss of Inequalities, Proceedings of the 4th International Conference on Well-Being in the Information Society, WIS 2012, Turku, Finland, August 2012, Communications in Computer and Information Science 313, Springer. This version has 50% new content.


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N.M.

N.M.

N.M.

D

S

D

S

S

D

D

D

Patient acuity system: Nurses assess patients’ care needs on a daily basis in a patient acuity system. Nurse managers can use patient acuity systems for staffing, scheduling, budgeting and management.

Patient classification system (PCS): When combined with other information, PCSs provides information for research, assignment of patients, manage staffing and budgets, analyse trends and workload, track performance, calculate costs, verify judgment and report.

Workload measurement systems: Acuity systems focus on nursing tasks or assessed care needs provide data and calculate a patient’s need of care. They can be used for nursing resource management, workload data reports and justification of more resources.

Patient aquity system: A system based on patient data and expert panels thoughts of care need for a specific diagnosis related group. Integration of patient acuity information with hospital resource measurements provides information for planning and budgeting.

Computerised ward management system (CWMS): The system improves the proportion of planned decisions concerning (staff allocation, ward administration, admissions/discharges, workload prioritising) on wards with low difficulty index rankings. Proper function of system requires engagement of all involved.

Patient classification system (PCS): Together with other information, a factor-based PCS can be used for allocation of nursing resources to meet patient care needs.

Nursing performance information system (NPIS): The system collects data of staffing, work environment, unit performance measurement and evaluation components providing information for quality assurance, staffing requirements, work conditions, attitudes and patient relationships.

Local area network (LAN): LAN improves access to information concerning human resources, patient information and finance. LAN saves time, improves communication and increases productivity.

Brown USA (1999)

Botter USA (2000)

Claudio USA (2004)

Diers and Bozzo USA (1997)

Fabray and Luck UK (2000)

Fralic USA (1989)

Gregory USA (1995)

Grinde USA (1994)

N.M.

N.M.

N.M.

N.M.

N.M.

N.M. and staff

D

Open shift management system: The system enables nurse managers to post vacant shifts online. Qualified nurses at six hospitals browse for suiting work and make requests for suiting shifts. ‘Justin-time’ shifts improve last minute staffing needs.

Bantle USA (2007)

Main users

Type of article

Description of information and communication systems D = descriptive, S = study, N.M = nursing management, N/R = research not reported

Authors country year

N/R

N/R

N/R

Effect on decision-making

N/R

N/R

N/R

N/R

N/R

Evaluation of system

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Appendix

Information and communication systems available for nurse managers in hospitals

Technologies for communication in a surgical ward 1 the tracking system provides information about locations of clinicians 2 the AwareMedia touch screen systems in different areas provide general information about the ward and are used to communicate between different stations 3 the AwarePhone system runs mobile devices with a phonebook, calendar bookings and locations of clinicians. Nursing management information system (NMIS): A data warehouse-based system integrating data about the patient, the clinical process (e.g., throughput time), personnel and financial perspectives. Data is obtained from several information systems and used for assessment of nursing performance. Clinical dashboard: The electronic health record-based system integrates patient information. It updates medical record information daily enabling evaluation of performance and monitoring almost in real time. This helps to improve the quality of care and mentor staff. The focus in the article is on electronic information systems in general. Nurse managers use systems for 1 human resource management 2 financial management 3 clinical management 4 communication. Nurse managers reported that these do not provide all needed information for decision-making. Nursing management information system: The computerised information system provides clinical data and reports of workload information for management of budgets and nursing resources. Nurse managers felt that the system did not support all information needs. ‘Six-pack-tool’: The tool combines data about department volumes, budgeted and total costs, patient satisfaction goals and scores, turnovers, hours per patient day and percentage of premium labour. The tool helps to utilise data and understand and explain budgets. Patient classification tools: These do not meet with nursing management information needs. Automated information systems can increase the quality of care and personnel efficiency, but they should be integrating and connected to a hospital wide information system.

Junttila et al. Finland (2007)

LaBranche USA (2011)

Lammin-takanen et al. Finland (2010)

Malone et al. UK (1997)

Mays et al. USA (2008)

Mowry and Korpman USA (1987)


Hansen and Bardram Denmark (2007)


D

D

S

S

D

S

S

Type of article

N.M.

N.M.

N.M.

N.M. and different personnel

N.M. and staff

N.M.

Medical, nursing and supporting staff

Main users

N/R

N/R

Questionnaires, financial data

N/R

N/R

Usability, relevance with a survey, interviews

Questionnaire, interviews


Information systems in hospitals 99

Information and communication systems available for nurse managers in hospitals (continued)

Nursing management minimum dataset (NMMDS): The system is based on nursing environment (e.g., patient population), nursing resources and financial resources providing information for quality measurement, analysis and care improvement. Simulation-based system for assigning patients: The system is developed for assignment of patients to nurses. It functions on basis of nurses’ workflows and patient data. Patient to nurse ratios are evaluated on the basis of this simulation. It is used at the beginning of a shift, but another system is needed for new patients. Database management information systems: Databases can be constructed for analysis of resource allocation, tracking subgroups of patients, data retrieval for clinical research, staff education documentation and information for reporting. The GRASP nursing workload management system: The system is based on calculations of workload and workforce. It was developed for a 1,200-bed hospital to quantify, record and analyse workload for evaluating performance and managing resources. Open-shift management system: The three-hospital-wide system was developed for effective staffing. Nursing staff chose open shifts and managers could decide rewards to motivate nurses. The system identified all open shifts across the organisation and let nurses know of available shifts matching their qualification. The system led to savings in costs and nurse managers’ time. The focus in the article is on information systems in general. Systems are developed for 1 communication 2 knowledge and skills 3 automated staffing and scheduling systems for staffing and managing budgets. Performance measurement systems: Information systems that store, retrieve, collect, analyse and compare data help identify areas for improvement can integrate clinical, financial and operational data. Automated workload measurement: The system evaluates work performance and recognises nursing resource needs based on staff scheduling and workload measurements by calculating hours of needed care and number of hours nurses need to work. ‘GIM whiteboard’: The electronic patient tracking system is visible across different areas and improves multidisciplinary communication from admission to discharge, through integration of real-time patient information including information from patient charts with notification triggers for different professionals.

Sundaramoorthi et al. USA (2010)

Tamarisk USA (1990)

Trundle et al. UK (2001)

Valentine et al. USA (2008)

Vautier et al. USA (2003)

Waldo USA (1997)

Walsh USA (2003)

Wong et al. Canada (2009)


Simpson USA (1997)


S

D

D

D

D

S

D

S

D

Type of article

Medical, nursing and allied health staff

N.M.

N.M.

N.M.

N.M. and staff

N.M. and infection control team

N.M.

N.M.

N.M.

Main users

Usefulness, effect on work practices

N/R

N/R

N/R

N/R

N/R

N/R

Usability, survey with students

N/R


100 L-M. Murtola et al.

Information and communication systems available for nurse managers in hospitals (continued)