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A Brief (and Biased) Story of the History of Nursing Informatics...

Having been around and involved for the relevantly recent history of nursing informatics development, I will attempt to capture as much as I can recall and retrieve for you to appreciate, ignore, or quietly criticize (keep it to yourself, please ;-) Constructive suggestions to improve this will be gratefully accepted. Having done this in previous years, I contacted some of my colleagues and asked them to elaborate their own (biased) stories and someday we'll compile a more complete history for future reference. Virginia Saba is working with the National Library of Medicine to compile Nursing Informatics history documents, and this effort should provide a terrific resource and legacy for our specialty over time.

If you think about the fact that the first computer that resembles what we're using today was first built in the 1940's then it would cause one to stop and think (perhaps) about why there isn't much health/medical system development for nearly 2 decades. Well, consider that the first computers were funded by the government and used for calculating weapons targets and message coding, and there was a World War in progress... Kind of a sad legacy and maybe accounts for something, I don't know? In 1958, the American Hospital Assn funded a feasibility study that recommended computer usage in hospitals for managing business office functions. And then things began...

MaryAnn (I think) Bitzer wrote OB nursing simulations as a part of her MS thesis in nursing in 1963. I can't find much info here...

The Technicon system was developed with $1-2 million federal dollars and was designed as a clinical system (this is really interesting when you stop and think about it), that was first installed at El Camino hospital in the Bay area of California in 1965. That same year (1965), 2 issues of the American Hospital Assn journal were devoted to data processing. IBM also began their SHAS system in 1965 - the acronym stood for Shared Hospital Accounting System. Think about it -- the mainframe was still at IBM but hospitals shared their data for processing with IBM's mainframes. The late 60's saw the release of products with acronyms such as IBS, MEDELCO, PROMIS, SMS, and McAuto. For the most part, these were data processing systems for financial/accounting/billing applications for charge capturing in hospitals.

Hospital systems of the 1960s developed as financial and business systems (with Technicon exception aleady noted), and this had a significant impact on later systems *as well as* (I think) the move toward profit-driven healthcare. What ever happened to providing health and illness care as a service?

Nursing informatics, as a term, hadn't been coined yet and the work was truly fledgling. Judy (Goodwin) Ozbolt was way ahead of her time trying to develop an expert system based on self-care models at the Univ of Michigan. Margaret Grier was studying nurses' information processing. Margo Cook was implementing the Technicon system at El Camino hospital in California. Nurses who were beginning to work in this area were Harriett Werley, Virginia Saba , and Pat Tymchyshym. I'm sure there are others that I don't recall just now...

My own personal story began in 1971 when I took a statistics course that required data entry and those awful punch cards (that I dropped...) Then in the late 1970's at the University of Minnesota Medical Center, when I was Assistant Director of Nursing (and Clinical Specialist) for the Level III Perinatal Units and Parent Education Program, we used a home-grown acuity system (called NUMIS - Nursing Unit Management Information System) that produced frequent and voluminous green-bar printed reports. NUMIS preceded Medicus and later products, but wasn't very different from materials you can still find at NIH (although you really have to dig for them with their redesign). NUMIS reports were mostly ugly and there was little accountability attached to them, so I usually glanced them over and tossed (or maybe filed, I don't remember). Anyway, we also had a group of folks called OAD (Operations Analysis Dept) and they came *with* the report one day and told me I had 2.0 too many FTEs (full time equivalents) in labor and delivery.8-(

The 1970s continued development of hospital systems with fancier ADT (admission, discharge, transfer) and order entry systems for more sophisticated charge capturing. We saw the beginning of capture of nursing tasks but these efforts either went the route of acuity systems or else failed (from everything I know anyway... - anybody have other info?) HBO made a progressive move to mini computers in 1972. Duke began their home grown systems in 1978 (including TMR I think) and a system called PCS was released that year.

Back in the days when Ritodrine was new, we were getting increasing numbers of high risk moms helicoptered in from remote backwoods areas of Minnesota and many of them really needed 2 nurses to 1 patient. I was disturbed by the facts that even experienced obstetricians were missing what *I* thought were obvious signs of early preterm labor. We needed 2 MORE nurses, not less... I tried to argue and advocate for what I thought was important, but those annoying OAD folks and their green-bar reports were infuriating and kept using jargon I didn't understand and indicated, basically, that the computer was ALWAYS right. Undaunted and unconvinced, I began taking computer courses so that I could argue with them! A little intro stuff and a BASIC programming class and I bought my first computer in 1981 (I think) - and Apple was the best personal computer available when I started this process (IBM had *just* released the PC and Atari and Radio Shack were the only others). Check out a terrific general computing history and this may help you place my Apple purchase within the context of computing history.

I learned enough to insist that the data OAD was using in their computers had to be wrong, and succeeded in having repeated time studies verify my hunches! (the link is for general info ONLY - save your $$ and we'll talk!) The uninformed who did those early time studies had little or NO idea what the nurses were doing and didn't bother to ask - they just punched the stop watches and wrote down what they *thought* the nurse might be doing... (A lesson here?)   Working and motherhood became too overwhelming when I also had to stop and deal with my brother's death.  After too short a break, I became a full-time doctoral student and naively thought I could study both nursing and the developing new field called 'informatics' and I had learned just enough about expert systems to be dangerous! So I set out to develop an expert system that would help nurses (and physicians) in the trenches be better able to assess preterm birth risk. That was 1983... My first informatics mentor was Margaret Grier, RN, PhD, FAAN, FACMI  who was completing a sabbatical with Dr Lael Gatewood in the Health Informatics Dept at the U of MN. Margaret's work was information processing and she was also editor for Research in Nursing and Health. Margaret and Harriett Werley published NURSING INFORMATION SYSTEMS (Springer Publishers) in 1981. This book had a significant impact by raising the profession's level of awareness... This was followed by (the 1983 article(s)). Margaret is a warm and charming Southern belle who spent many years in Chicago wnet to the University of KY, and is probably retired now.   Her own work took a different turn when her son experienced a serious trauma, and you'll not find Margaret amongst the ranks of much happening in NI now, but her earlier role was incredibly  influential in shaping the developing field.

A group of early pioneers got together and published two similar articles in nursing journals in 1983. I can only find one of them just now: Computerized Nursing Information Systems (NIS)* Nursing Management 14(7), 26-29. Authors included Marlou Kiley, Ed Halloran, Jerry Weston, Judy Ozbolt, Harriet Werley, Marjorie Gordon, Phyllis Giovannetti, John Thompson, Roy Simpson, Rita Zielstorff, Joyce Fitzpatrick, Stephanie Davis, Margo Cook, and Margaret Grier. The articles articulated the authors' concerns that if nurses didn't GET involved in computers and system development that there would be negative consequences for our profession. Shortly after the articles were published, the ANA got busy...

The ANA formed a Council on Computers in 1983. There was a surge of interest and development in nursing CAI (computer assisted instruction). Hospital systems had expanded to include more sophisticated order entry and some capture of nursing tasks (in a few systems).

The US Dept of Health and Human Services sponsored a 2nd National Conference on Computer Technology and Nursing in 1984 (seems safe to assume there was a first one, but I only have a flier for the 2nd)... The folks who presented at this were Margo Cook, Nancy Light, Ruth Carlsen, DeLanne Simmons, Carol Romano, Linda McNeely, Kathleen McCormick, Virginia Saba, and Carolyn Tindal.

I ran into conflict with one Health Informatics professor who didn't think nurses should be programming, and I had watched and learned enough to realize I wasn't a very good programmer anyway! My peers would write a few lines of code in much more clever fashion than my longer and clunkier programs. The end result was much  the same, but I began to appreciate clever and efficient coding. And I had learned enough to be able to communicate with them and discriminate good from not-so-good programming code (at the time, but it was before C and Java remember!) . My early readings were suggested and shared by Margaret Grier, and she summarized most of what I read in a review chapter (we'll read during the program)... The effects of Margaret's influence, my programming experience, and my interest in expert systems steered me toward Paul Johnson and the Decision Sciences department. I took everything he offered and was truly humbled in a class of *really* smart people and by Dr Johnson who was incredibly brilliant.  My time in MN gave me varying degrees of exposure on DEC and CRAY mainframes as well as teletype machines and acoustic phone couplers. I gasped when I saw how ugly and unfriendly the first version of WordStar was and was exceedingly critical and stubborn about learning DOS commands because I *knew* those programmers could do better ;-)

I attended my first SCAMC (Symposium for Computer Applications in Medical Care) meeting in Baltimore in 1983. There were about 10-12 nurses who showed up for a Nursing Working Group meeting and one REAL (non-nurse) nut. I forget his name, but he was a consistent character in the NWG for many years, and kept emphasizing that nursing really needed to get its act together! I was totally excited and overwhelmed to learn a lot about what vendors were developing and what other nurses were doing in informatics. I was so new to it all, I don't remember who I met, except that Carol Ostrowski was Chair of the Nursing Working Group. The field was small enough that it was possible to know EVERYONE and read EVERYTHING and know ALL the vendors' products! Times do change... and so quickly!

I took a part-time job as a Research Nurse for a large HMO in Minneapolis and rigged up a system where I could talk into a headset to do phone interviews and type their answers directly into my Apple computer. It was a really slick system compared to my co-workers who wrote everything out by hand and then typed it. My ex-priest boss got testy with me at one point and insisted my computer must have screwed up the data -- my patient interview results were complimentary of a group of physicians for whom he wanted to report negative findings to the HMO Board. After he suggested I might falsify my data, I changed jobs! Same organization but I started a new Clinical Specialist position developing prenatal education programs, and was asked to help write an outpatient RFP (request for [computer system] proposal) because of my computing interests. Oh, and it was one of these physicians who insisted that if I was going to study computers, I *had* to read Pirsig's 'Zen and the Manual of Motorcycle Maintenance'. (I *highly* recommend it and the sequel, 'Lila').

Linda Lange wrote that in 1983 at  UT-Austin sponsored an NI conference, and this was her first NI meeting. She later went on to head up the NI program at the University of Utah. Linda L. recalls that CAI stuff was a major focus at that conference, and they had some program on how to do injections with a bit-mapped type graphic image of a syringe filling up to the user-specified mark -- thank goodness we've come a long way. Gary Hales had just started his newsletter, which later became "Computers in Nursing" when moved to Lippincott. Gary contributed a lot to launching this CIN journal, but sadly passed away in 1996 after a long battle with a brain tumor.

In 1985, Lael had some of us participate in writing portions of an IAIMS grant. And I got an invitational spot at the International Nsg Informatics meeting in Calgary. I got to meet and work with all those folks I had been reading. Patti Brennan and I were the new kids on the block, but folks like Harriet Werley and Judy Ozbolt and Kathryn Hannah had been working to develop the field for nearly a decade! I have the proceedings in my office, and if you care to review it sometime when you're on campus, you'll see the names of some of the founders of the developing field of Nursing Informatics. If I sometimes get a little cynical and critical that many of these folks have now been by-passed, PLEASE remind me that their contributions were valuable and significant in their time, and I hope we will always pay respectful tribute to those who paved the way... Those already named and Kathleen McCormick, Susan Grobe, Sheila Ryan, Judy Ronald, Linda Edmunds, Roy Simpson, Diane Skiba, Pat Schwirian, Mary MacLindon, Carol Romano, and many more...

While it might seem obvious to others, the 1985 Calgary conference was my first exposure to the International group that made me aware that the USA was definitely not the leader in much of the informatics world. Germany and Scandinavia and Australia and the UK and Canada were doing awesome work in 1985, and that has continued over the past two decades. And I'm sure I'm leaving out people's names and important countries -- but remember that this is a *biased* story told from my personal experiences and filters.

Harriett Werley organized a group for the first Nursing Minimum Data Set (NMDS) meeting in 1985. Many will laud this work as historic. I tend to be a cynic here and will share my thoughts in our class discussion forums. My consistent and major complaint with this work was the inclusion of patient name (and other identifiers) in a foundational data structure. My area of interest in privacy and security issues developed in the early 1980's and I don't believe the NMDS folks adequately addressed this issue. Nevertheless, the group that Harriett organized and the motivation behind this work has had a significant impact on our profession and developing NI specialty, and was pioneering effort for its time. In its purest form, the NMDS was our first attempt at standardizing data, which led to the awareness that we must also standardize our language. ANA recognized NANDA as the first taxonomy of nursing in 1986. In its pioneering role that raised awareness, I think the NMDS work launched important contributions that have contributed to the development of nursing informatics.

UCSF offered a summer Microcomputer Institute for Nurses and Health Care Professionals in 1985. William (Bill) Holzemer is the only name I recognized. The flier I found indicated this was at least the second time they had offered this program and there was also an advanced institute but I have no more information.

The National Center for Nursing Research (NCNR) was founded in 1986 and focus groups which followed from 1988 to 1993 included an expert panel for nursing informatics with Judy Ozbolt as Chair (more detail comes later).  I can't remember what year they changed the name from "center" to "institute".

Unable to find a nursing advisor who was willing to sponsor my informatics research interests, and combined with a family crisis, I moved to MO in 1986. This turned out to be a wonderful detour. For six years, I worked as Director of Nursing Information Systems for Children's Mercy Hospital in Kansas City, MO. This place had the most awesome work group I've ever known, an early development and commitment to CQI/TQM and teamwork, and state of the art SMS (Shared Medical Systems) architecture and mainframe (Independence) systems. A 157 bed hospital spent approximately $3 million to install this system in 1986-87! I started out with a team of 3 other nurses and a support person as billing liaison, and there was another whole separate (and much larger) Data Processing (later changed to Info Systems - IS) Dept. There is NO substitute for real-world, on-the-job training! The politics and organizational systems that caused both the successes and the failures in my six years there were some of the most incredible learning of my entire career! These stories are bound to slip out as the next few months unfold... While you may be tempted to point out that my experience is now old, I can assure you the issues and stories that surface every single year in our program, and everywhere I travel on the globe, find that while politics and players may change and health care is in various states of chaos and reform, the issues remain  pretty much the same!

I took the job at Childrens for three important reasons: First, it reported directly to the VP for Nursing. Second, everyone (including the hospital administrators) assured me (during the interviews) that they had full physician support for MDs to enter their own orders. Here is where the long stories begin  8-)   Third, I was told I could immediately begin work on *Nursing* applications!

Within one month, and right before we left for training at SMS corporate headquarters, my VP for nursing boss informed me that it would be necessary for me to help with ADT (admission-discharge-transfer) implementation before there would be anything to build for nursing applications. This was a bit of a disappointment, but not a surprise, and I thought it would be a good learning experience (which it was). I found ways to make even the ADT functions improve nurses' jobs -- for example, printing forms in their busy triage area so that the date, time, demographics, and med rec # did not have to be handwritten. The usual sequence is to build Order Entry functions next, but the conflict over MD versus RN versus Unit Secretary order entry hit early and subtly, and top level administration was unable to make a decision, so we all went off and did other sorts of building. Using the SMS architecture from 1987-1992, my team developed:

• On-line documentation for OR nurses that included 3 minute BMT cases (ear-tubes).
• Discharge planning applications for the Clinical Nurse Specialist(s) who performed these functions.
• Clinic scheduling (Resource Scheduling System) for a multitude of large and small outpatient clinics.
• On-line nursing protocols and procedures.
• Allergy records.
• Immunization records.
• ER logbook.
• I'd have to go find my old notes to keep going - the list was LONG!!!

There was an International NI meeting in Dublin, Ireland in 1988. I haven't seen or heard much about this one other than the few I know who went had a wonderful time as tourists! Although I would have loved to go, we were in the middle of rigorous implementation schedule and I couldn't leave my new job... <rats!>  I also don't have any info on what would have been a subsequent meeting in Korea, I think  (1991).  I was writing a dissertation and didn't even think about going to that one.

The basic theme of hospital systems during the 1980's was expansion and integration. Seeing an opportunity for incredible profits, the numbers of vendors and the applications for health care, hospitals, nursing, ancillary departments, etc. saw exponential growth in the 1980s - to the point where it was impossible to keep track and really know everything about all possible systems. The 1980s saw the development of laboratory information systems (LIS), radiology information systems (RIS), nursing information systems (NIS), and why don't they have a similar acronym for pharmacy systems? ;-)   There was a beginning movement toward the development of CLINICAL information systems (CIS) in the late 1980s. Companies like Cerner had a wonderful reputation for having the best lab system in the business (at the time anyway). Cerner decided to capitolize on this reputation and develop a full blown integrated clinical system. They're still developing this more than a decade later. Any ideas why this process takes so long and costs so much? Many of the big companies (like Cerner, HBO, SMS went through a brief phase where they tried to make everything mainframe driven and very integrated within their own software constraints. But the marketplace balked, and by the 1990s, you find most companies of all sizes moving toward desktop, networking, and workstation (PC) platforms. The mainframe has became just another peripheral on the network! (in many/most places)...  Remember this as we begin to talk (a 2000 phenomenon for sure) about applications service providers (ASPs)!

The ANA published a task force project entitled Computer Design Criteria for Systems that Support the Nursing Process in 1988. The task force and publication were the work of Rita Zielstorff, Mary McHugh, and Jackie Clinton.  The Univ of Utah tried to offer a summer post-doctoral program in hands-on informatics work in 1989. Well they actually did offer it. I know someone who attended and thought she'd learned some good stuff. But another good idea got dropped along the way for reasons I could guess, but do not know for sure...

The University of Maryland at Baltimore started their graduate program in Nursing Informatics in 1989. Names you'll find associated with the UMAB program include NIH's Carol Romano, UMAB's Dean - Barbara Heller, MaryEtta Mills, and Carole Gassert.  That program grew too large too quickly, and recruiting and retaining qualified faculty was difficult with the heavy teaching loads required.  I think the University of Utah program began shortly after UMAB's. Judith Graves was largely responsible for starting the program in Utah. She left to work for Sigma Theta Tau, and the program has been sustained through the efforts of Cheryl Thompson and Linda Lange (see picture below). Linda left the Univ of Utah to do 'real' world systems, but wrote back to my questions with the following info:

The NI program at Univ of Utah was started via a grant from the Division of Nursing, PI-Judith Graves, funded in late 1989. First students were admitted in Fall 1990. This was designed as a "clinical" NI program to distinguish it from Maryland's program, which had/has? more of an administrative focus. This was to appeal to funding sources, as well as to respond to what was seen as a critical need for clinical nursing informatics. Also fit in well with the various activities in medical informatics ongoing here.

The first informatics conference I attended was in 1983 at the U of Texas, Austin. Gary Hales had just started his newsletter, which later became "Computers in Nursing" when taken over by Lippincott. As I recall, CAI stuff was a major focus at that conference.

Full citation (ANA link and article no longer available, sorry):  Graves, J. & Corcoran, S. (1989). The Study of Nursing Informatics. IMAGE: 21(4), 227-231.

The National Commission on Nursing Implementation Project was based out of Milwaukee (and funded with Kellogg $ I believe), but was a good idea that never went much of anywhere. In December of 1990, a bunch of NI folks met with vendors in Orlando, FL and generated some great questions, good discussion/debate, and summary reports that were not widely circulated. I have a copy somewhere if anybody wants to see a little of what happened here.

I missed the International NI meeting in Sydney, Australia in 1991. I'll need to have someone fill this in because from all reports, it was another really wonderful conference. Gordon Larivee (see picture below) also started up the nrsing-l discussion list in 1991.  The nrsing-l was moved from Gordon's turf at UMass (who decided they would no longer support it) to the AMIA Nursing Informatics Working Group in 1999.

ANA's Congress of Nursing Practice recognized nursing informatics as a distinct area of specialty nursing practice in 1991.   Not required reading: *Milholland, K. (1992). Congress says informatics is nursing specialty. American Nurse. July-August.

There is a LONG story (gee is this one short?) about how I ended up back in a doctoral program at KU working on a minor with Dr Jerzy Grzymala-Busse in computer science. You'll hear more about this during the next year. But as I finished my PhD in 1992, I realized a need to consider changing jobs, and did that. (Univ of MO -Columbia 1992-1995). Whether it was intuition or luck, I'll never know, but the CEO resigned the same week I did! And the subsequent events at Children's found a whole new team of administrators who ditched the SMS system in its seventh year (and all the nurses who worked on it) and replaced it with their favorite - a Meditech System. Rumors said the cost of the new system was closer to $1 million, making it a real bargain, right? 8-|

I finished my PhD in 1992 (Univ of KS - major = nursing; minor = computer science). I switched to academia and the University of MO-Columbia (which was my old home town) and thought I'd settle down for the long haul. The informatics folks at Mizzou are really great. And some of my nursing colleagues were wonderful. About the time I started the new job, an earlier small business research grant (SBIR) was suddenly and unexpectedly funded and I found myself completely crazy trying to do a bunch of new things. I worked with Michele VanDyne of IntelliDyne and developed an expert system that predicts birth outcomes better than anything that exists so far. We couldn't agree on ownership at the end of our Phase I funding, so parted company in anger for awhile, and later reached an agreement that our friendship was what we wanted to sustain and the business stuff would just have to go elsewhere.  Michele went  on to pursue her PhD (2004) and continued to run a very successful small business and is a true rocket scientist -- building and testing expert systems for the NASA space shuttles (yes she has actually been inside them but only on the ground thus far).  I took my portions from our joint work and was successfully  funded (1997-2003) by the National Library of Medicine.  Michele and I have teamed up, once again, for proposals that are currently under review.   The folks at Mizzou 'let' me teach the first nursing informatics course in Missouri (1995) and that launched similar courses for other nursing programs around the state. But ultimately, a personal life change and greener pastures called me to North Carolina.

Although I had been doing e-mail and using the Internet for remote data analysis, I first loaded TCP/IP, SLIP, and Mosaic in 1992. While Mosaic was pretty slick, what you could access on the WWW was still lots of gopher stuff, text, and ugly. It took forever to wade through what you did find to see if there was anything useful there. If there was a search engine available in 1992, I didn't find it...

The ANA Council on Nursing Informatics began the process of developing a Scope of (NI) Practice in about 1993 and this was first published in 1994. The Standards of (NI) Practice followed shortly thereafter and were published in 1995. Shortly after this, the Council on Nursing Informatics was absorbed into the ANA Board of Systems and Administration.

The National Center (later Institute) for Nursing Research published "Developing Knowledge for Practice: Challenges and Opportunities" which outlined a national nursing research agenda in 1993. Informatics is listed and an expert panel was convened under the direction of Judy Ozbolt (you'll find the panel's report (skim - don't read in detail) listed in the proper time context below)...   Dr Ozbolt has been my ongoing mentor, colleague, and friend and I've learned a great deal from her -- especially things about professionalism and patience that I've learned better from her example than anything anybody could have told me...! The NCNR Report reflects the complex nature and issues of informatics in nursing. What has been disappointing is that leadership changes at what became the NINR (now an Institute) resulted in priority changes that directed $$ away from informatics research unless a clear and direct link to patient (clinical) outcomes could be demonstrated. This is/was premature in our stage of professional development (IMHO).

In 1993, I found nrsing-l and Jack Yensen and a bunch of other folks who were actually DOING neat things in informatics and not just blowing a lot of hot air at conferences... (yes, this could get me in trouble but this is a biased story, right? ;-) I believe this was the year that ANA got a bee in their bonnet (and some funding from the Divison of Nursing) to set up Nurse*Forum. Their plans were clearly profit driven and you had to sign a form (they snailmailed to you at first) and it was only a very short time when their planning ran head to head with a VERY different philosophy on the part of WWW users. Slowly they have migrated things to the Web but haven't abandoned their profit motive entirely, as you will see if you try and access ANA now....

Jack Yensen says he first put the Virtual Nursing College on-line in 1993. I first saw it in 1994 or 5.

The San Antonio NI meeting:

I wish I had pictures of the 1985 Calgary group (and don't) so was more diligent about capturing history at the International Nursing Informatics conference in San Antonio in the summer of 1994. Actually it was a great time to network with old friends and colleagues and develop new... I'll never make a living as a photographer and was VERY disappointed that my picture of Harriett Werley was too dark to use, so I'll keep adding to this collection! Most of these pictures were taken at a banquet where they taught line dancing in some fancy ballroom. Typical of those crazy Texans, don't you think!

This is my mentor, Margaret Grier (left) who launched me into this field with solid advice about the need to understand information processing (theory), publishing, and family priorities and balancing acts. Patti Brennan (right) has a PhD in management engineering (Univ of WI) and launched a successful NI research career from Case Western Reserve in the late 1980's. Patti's work has studied the impact of laptops and computers in the home of AIDS (and other) caregivers and how they found the technology useful for support of the caregiver. She returned to Wisconsin in 1997 or 8 I believe. Patti is one of the most flaming E's (extroverts) I've ever met. She's charming and engaging and sells herself very well, so you'll find her in LOTS of places where NI is a topic. She is the only nurse to serve as AMIA president (2000-2002)



Barry Jones (left) is an exceedingly funny psychologist from Glasgow, Scotland. He did fascinating and pioneering work comparing machine learning techniques to other methods for knowledge base work.  Gordon Larrivee (right) is the guy who established and moderated the first (and once the best) nursing informatics discussion list.



Kitty (Caton) O'Meara was an NI specialist at the VA in Portland, OR and working on her doctorate at the University of Oregon. She was just beginning her disseration at the time of the San Antonio conference, and joined me in taking Barry J. on for scholarly debate about how MUCH data we needed to mine. Kitty's disseration was completed in 1996 on the topic of 'usability' and she is a warm and honorable soul who is willing to share. She is now on faculty at the University of Oregon.



Sue (Henry) Bakken  is rosy-cheeked because she'd rather dance than just about anything. Since I had no idea who she was dancing *with* I cropped him off! Dr Bakken completed a Medical Informatics MS program (in addition to her PhD) with Ted Shortliffe at Stanford, and her nursing vocabularies/standardization research is setting the pace for our profession. She was Charlie Mead's mentor for the post-doctoral work he completed at the University of California-San Francisco.



Cheryl Thompson (left) and Linda Lange (right) are the  folks who ran the (clinical) Nursing Informatics program at the University of Utah. Linda  moved on to run state-level public health databases and other things and Nancy Staggers joined Utah's faculty in 1998.  Rita Halpern-Snyder was also on Utah's faculty for awhile.  The faculty at Utah all left in 2002, and the program has been slow to rebuild.


I first met Charlie Mead  (at left) at NI '94 in San Antonio (no it was NOT the 'Love Boat' but one of those canal boats they used to shuffle folks around - it was summer). I was intrigued to see MD on his name tag attending a *nursing* conference.   He took me to breakfast and showed me a pen-based system he was developing for home health nurses, and told me a little history. I think it goes without saying that I was impressed!  It is Charlie's fault that you have to learn something about object oriented analysis and design (OOAD) and unified modeling language (UML).

The ANCC generalist level certification exam in Nursing Informatics was first offered in October of 1995.  There is currently a debate (altho futile) about the BSN requirement to sit for the exam, now that ANA and ANCC have developed an "Open Door" policy that says education doesn't matter.   At present, there are no plans in progress for developing a certification exam for the INS (specialist) level, although there is MUCH  discussion about the need for the specialist certification.

I came to Duke in January of 1996.   We began a Post-Master's Certificate ONLINE at Duke in January 1997.   Our online program was the first of its kind anywhere in the world.   MSN students could take the courses as a minor, but the majority of our early students were advanced practice nurses who were already in an informatics role or aspired to one.  Because we were ahead of the curve, every single online course item was hard-coded in html for the first group.  It was tedious but also fun the first time; the maintenance and updating became a real chore, however, so I began using a courseware platform developed by Lotus (Domino/Notes) with the second group (courseware had been purchased for an online FNP program funded by the RWJ foundation).

I know folks who attended the International Nursing Informatics conference in Sweden -- September 1997. I am published there but my joint appointment boss actually presented our papers.  I have a copy of the proceedings that were brought back but don't have much information about the conference actually, and hope if any of you were there that you will tell us more about it.

The Nashville AMIA meeting in the fall of 1997 presented our first Pioneering group and efforts WRT Dukes' Nursing Informatics program. It was a great place to network and find out what the rest of the informatics world is doing.  I can't believe we don't have any pictures of this event but I don't have any and haven't been successful in finding any from those who attended.  Will keep trying.

I need to add a few pictures of the pioneering grads from our inaugral graduating class of 1998!

The basic theme(s) of the 1990's were many. IMHO, the main ones included standardization, resurgence of concerns for privacy and confidentiality, everything related to quality (ala TQM, CQI) and managed care's focus on outcomes. And then, of course, the proliferation of global networks and the Internet/WWW changed the face of the world forever, and that includes the face of healthcare (I think).
 
 

Auckland, New Zealand 2000	Our own Duke Ed Hammond gave the  keynote speech	Kathleen McCormick (Where now?), Ed Halloran (UNC), and ??
Virginia Saba (True Pioneer and Leader in NI)	Some of our Dookie 2000 alums  Vicky Elfrink (OH), Brenda Laurie-Shaw (Canada), Shirley Tierney (MA), Kathy Williams, (SC)  and Dr. G	Jim Turley (UT-Houston) and ??
Karen Martin (OMAHA Developer), Patti Abbott (Johns Hopkins), Roy Simpson (Cerner), and 1999 Dookie -Norm (Mac) McIntyre	Dookie NI Kathy Williams (2000) won the contest and became the reception Queen!  These NI conferences always include parties  8-)	No picture here...  Yes, I need to revise this format to deal with image downloads more efficiently - I know!  Maybe next week in my spare time?

In 2002, Duke began offering a full online MSN in Nursing Informatics, with funding support from HRSA/Division of Nursing.  We were blessed with additional CIT funding from Duke.  With these multiple funding sources, we were able to provide loaner equipment to incoming informatics students to use for the duration of their NI program.  They received new Dell laptops, Axim and Palm (m130)  PDAs, web cams and microphones.  We launched this inaugural group in fall 2002 with a campus session.  It sure made things nice for both faculty (less tech support with all standardized equipment) and nice for students (software versions, hardware compatibility, etc.)

As we  enter a new millenium, Jack Yensen chides many of us in nursing -- that we are finally entering the 20th century where technology and informatics are concerned. Distressing numbers have not even made it that far... But the field is definitely evolving - for better or for worse. One can no longer easily read all the literature in nursing informatics, let alone medical and health care informatics. The vendors proliferate and merge and new ones start and old ones fail at a pace that few of us can keep track of them all. It is impossible to stay abreast with everything one would like to know about emerging hardware and software technologies. And the new machines we so carefully spec and purchase are obsolete almost as soon as we unpack them from the box!

In the early 1980's (I think - should check), Naisbitt and others predicted the information age was upon us and we would be inundated with data and information. I believe they were right about this one! *But* they also predicted we'd be working from home on our machines and we'd have harnessed technology to make our lives easier and provide us with more free time. This would be called 'working smarter' -- Do you find this happening in your own life?

The literature suggests (and I certainly hope) that the new millenium will bring data-driven decision support for nurses (and all folks who work in health care). My crystal ball is a little cloudy today so predictions will be forthcoming later...

In closing, I hope that you will think creatively and critically about how the technology that has come before, overwhelms us now, and is evolving for our future will shape who we are as people and as nurses...