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 N11588
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NURSING AND INFORMATICS
for the 21st Century
An International Look at Practice,
Education and EHR Trends
Second Edition

Edited by
Charlotte A. Weaver
Connie White Delaney
Patrick Weber
Robyn L. Carr
CRC Press
Taylor & Francis Group
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 iii

About the Editors

Charlotte Weaver, PhD, RN, MSPH, FHIMSS, is Senior Vice President and Chief Clinical
Officer for Gentiva Health Services, Atlanta, GA, and serves as Adjunct Professor at the Uni-
versity of Kansas School of Nursing and the University of Minnesota School of Nursing.
Previously, she was with Cerner Corporation from 1999 to 2008 where she served as the first
Chief Nurse Officer in the IT industry until May 2007. Dr. Weaver then moved into the posi-
tion of Vice President and Executive Director for Nursing Research—a new and uniquely
created role to foster nursing research. Her informatics career started in academia at the Uni-
versity of Hawaii in 1981 and over the intervening three decades has covered every side of the
industry—software supplier, consulting and provider in the United States, UK, Europe, Can-
ada and Australia. Dr. Weaver has served as part of the TIGER Initiative (Technology Infor-
matics Guiding Education Reform) since its inception in 2004. She has been a long standing
AMIA and NIWG member and is currently NIWG chair. She has served as corporate member
to the International Medical Informatics Association, Nursing Informatics Working Group
(IMIA-NI) from 2004-2008; she currently chairs IMIA-NI’s evidence-based nursing practice
working group. Dr. Weaver is a HIMSS Fellow, a member of HIMSS’ Nursing Informatics
(NI) Community and served as NI Committee chair for 2007-2008. A frequent presenter at
national and international conferences, Dr. Weaver is widely published in informatics, patient
safety and quality, and evidence-based practice.

Connie White Delaney, PhD, RN, FAAN, FACMI, is Professor and Dean of the School of
Nursing at the University of Minnesota. Dr. Delaney is the first nurse informatician Fellow
in the American College of Medical Informatics to be selected as dean for a major university
in the United States, a position she has held since August 2005. She also holds an appoint-
ment in the Institute for Health Informatics, University of Minnesota. Dr. Delaney has held a
professorship at the University of Iceland, Faculty of Medicine and Faculty of Nursing, with
focused activities in health informatics for 10 years. Prior to her deanship position, she held a
full professor position at the University of Iowa, College of Nursing, where she led the nursing
informatics graduate program, directed the Institute for Knowledge Discovery, and served as
director/co-director of research teams; these teams included the International Nursing Mini-
mum Data Set, USA Nursing Management Minimum Data Set, and USA Nursing Minimum
Data Set. In addition, she led development of evidence-based nursing protocols translated to
automated clinical information systems and data mining of large data sets. Dr. Delaney cur-
rently serves on numerous boards, including the LifeScience Alley, a Minnesota-based trade
association in the Upper Midwest focused on the life sciences; the American Medical Infor-
matics Association (AMIA), and the American Association of Colleges of Nursing, Premiere
Quest National Advisory Panel. She serves as the U.S. Government Accountability Office
(GAO) appointee to the Health Information Technology Policy Committee, which is charged
with making policy recommendations related to the nation’s health information technology
infrastructure. Most recently, she co-edited the October 2008 special issue of Nursing Outlook;
this issue focused on Nursing Informatics as a strategic initiative of the American Academy
of Nursing.

Patrick Weber, MA, RN, is Director and Principal of Nice Computing in Lausanne, Swit-
zerland. He has more than 30 years of healthcare experience, with more than 20 years in the
field of health informatics. Mr. Weber has served as his country’s national representative to
IMIA-Nursing Informatics for over ten years and is a recognized informatics leader across
Europe. He has been a pivotal leader in the European Federation for Medical Informatics
iv Nursing and Informatics for the 21st Century, Second Edition

(EFMI) holding numerous offices in EFMI and in Switzerland’s Nursing Association. Mr.
Weber works extensively across Europe and is a frequent collaborator on informatics projects
across the European Union countries. He has numerous publications in both English and
French and is a frequent presenter at national and international conferences.

Robyn L. Carr, RGON, is Director of Informatics Project Contracting at IPC & Associates,
Cambridge, New Zealand. Prior to starting her own IT consulting company in the Asia-Pacific
Rim countries, Ms. Carr served in various clinical management and administrative positions
in New Zealand Health Services for over 35 years. In her consulting business, she has served
as an international consultant for IT initiatives in countries as far ranging as Taiwan and
South Africa. She was a founding member of the Health Informatics New Zealand in 1991
and has been a member and active leader since that time. In addition, Ms. Carr has served as
New Zealand’s country representative into the International Medical Informatics Association
(IMIA) Nursing Informatics – Special Interest Group for the past 15 years. Her leadership on
the international level resulted in her winning host country bid for the International Nursing
Informatics Congress of 2000, and holding numerous board positions within IMIA-NI-SIG,
including chair (2006-09). Ms. Carr is widely networked and well respected internationally.
Ms. Carr co-authored NINZ the first 10 years, published in 2000, and is co-editor of “One
Step Beyond: The Evolution of Technology and Nursing,” the 7th International Congress Nurs-
ing Informatics Proceedings.
Contributors
Outi Ahonen, MNSc Claire Buchner, MSc Health Informatics,
Senior Lecturer BSc(Hons) Nursing Studies
Department of Social Services, Health and Teaching Fellow
Sports School of Nursing & Midwifery
Laurea University of Applied Sciences Queens University Belfast

Suzanne Bakken, DNSc, RN, FAAN, Laura J. Burke, PhD, RN, FAAN
FACMI Director
Alumni Professor of Nursing Department of System Nursing Research
School of Nursing & Scientific Support, c/o Aurora Sinai
Professor of Biomedical Informatics Medical Center
Department of Biomedical Informatics Aurora Health Care
Columbia University
Helen K. Burns, PhD, MN, BSN, RN, FAAN
Marion J. Ball, EdD, FACMI, FCHIME, Associate Dean for Clinical Education
FHIMSS, FAAN School of Nursing
Senior Advisor University of Pittsburgh
Healthcare and Life Sciences Institute
IBM Research Andrew F. Carlson, BS Systems Analysis
Professor Emerita Strategic Program Manager
Johns Hopkins University School of Department of Information Systems
Nursing Aurora Health Care

Cristina Barrios, BSN Anne Casey, MSc, RN, FRCN

Department of Nursing Direction Royal College of Nursing, UK
Favaloro Foundation – University Hospital
Mary Chambers, PhD, BED(Hons)
Claudia Bartz, PhD, RN, FAAN Professor of Mental Health Nursing
Coordinator, International Classification for Faculty of Health and Social Care Sciences
Nursing Practice (ICNP©) St. Georges University of London/Kingston
International Council of Nurses (ICN) University
College of Nursing
University of Wisconsin-Milwaukee Polun Chang, PhD
Associate Professor
Lejo Bouma, RN Institute of BioMedical Informatics
Department of Youth Health Care National Yang-Ming University
CARE
Insook Cho, PhD
Suzanne Brown, MSc Health Informatics, Professor
BNS Department of Nursing, School of Medicine
Assistant Nurse Coordinator, Computer Inha University
Sciences
Department of Information Management Lynn M. Choromanski, MS, RN
Mater Misericordiae University Hospital Nursing Informatics Specialist
Department of Nursing Administration
Gillette Children’s Specialty Healthcare

v
vi Nursing and Informatics for the 21st Century, Second Edition

Thomas R. Clancy, PhD, MBA, RN Kelly Marie Damon, MAL, BSN, RN

Clinical Professor Director
School of Nursing Department of Nursing
University of Minnesota Oasis Hospital

Amy Coenen, PhD, RN, FAAN Walter De Caro, MNs, DAI

Director, International Classification for Head, Nursing and Health Profession
Nursing Practice (ICNP©) Service
International Council of Nurses (ICN) Minister of Defense (Italy) – General Direc-
College of Nursing torate Military Health Services
University of Wisconsin-Milwaukee Public Health Department
University Sapienza Roma (Italy)
Beverly J. Collins, MS, RN
Research Fellow Elizabeth C. Devine, PhD, MSN, RN
Institute for Health Informatics Professor
University of Minnesota College of Nursing
University of Wisconsin-Milwaukee
Rita W. Collins, PhD, MEd, BNS, RN, RM
Lecturer Charles Docherty, PhD, MN, MBCS, BN,
School of Nursing, Midwifery & Health RN, RNT
Systems Royal College of Surgeons in Iceland (RCSI)
University College Dublin
Beth A. Donahue, MA, BAN, RN-BC
Jennifer Conner, BA Assistant Professor
Engagement Leader, Consulting School of Nursing
Cerner Corporation The College of St. Scholastica

Helen R. Connors, PhD, DrPS (Hon), RN, Donna B. DuLong, BSN, RN

FAAN
Executive Director Nancy E. Dunton, PhD
Center for Health Informatics Research Associate Professor
E. Jean M. Hill Professor School of Nursing
School of Nursing University of Kansas Medical Center
University of Kansas
Nighat Ijaz Durrani, MPH(PAK), Dip in
Robyn Cook, MBA, BBus, RN Administration & Teaching, Opthlamic
Honorary Associate Nursing UK, RN, RM
Faculty of Nursing & Midwifery Registrar
University of Technology, Sydney Pakistan Nursing Council

Karen L. Courtney, PhD, RN Patricia C. Dykes, DNSc, MA, RN

Assistant Professor Corporate Manager, Nursing Informatics
Department of Health and Community and Research
Systems Department of Clinical Informatics
University of Pittsburgh School of Nursing Research and Development/Information
Systems
Grace T.M. Dal Sasso, Nursing Informatics Partners HealthCare
PhD, RN
Adjunct Professor Margareta Ehnfors, PhD, Dipl NEd, RN
Department of Nursing Professor
Federal University of Santa Catarina School of Health and Medicine
Orebro University
Contributors vii

Anna Ehrenberg, PhD, RN Ayala Gonen, PhD, RN

Associate Professor Nursing Informatics Manager
School of Health and Social Sciences Department of Nursing
Dalarna University Tel Aviv Souraski Medical Center

Scott W. Eising, BS William T.F. Goossen, PhD, RN

Director, Product Management Director
Department of Global Products and Results 4 Care B.V.
Services
Mayo Clinic A.T.M. Goossen-Baremans, MSN, RN
Results 4 Care B.V.
Anneli Ensio, PhD, RN
Research Director Brian Gugerty, DNS, MS, RN
Department of Health Policy and Owner
Management Gugerty Consulting, LLC
University of Kuopio
Herdís Gunnarsdóttir, MSc, MBA, BSc, RN
Firdevs Erdemir, PhD, RN Project Manager
Associate Professor Department of Development, Nursing
Department of Nursing Chief Executive Officer Office
Baskent University Landspitali University Hospital

Sally K. Fauchald, PhD, RN Kathryn J. Hannah, PhD, RN

Associate Professor and Chair Executive Project Leader
Department of Graduate Nursing Canadian Health Outcomes for Better
The College of St. Scholastica Information and Care
Health Informatics Advisor
Myriam Martin Fernández, PhD, MSN, RN Canadian Nurses Association
IA, Nurse Leader
Spain Services Nicholas R. Hardiker, PhD, RN
Cerner Iberia Senior Research Fellow
School of Nursing
Daniel Flemming, Dipl. Kaufmann, RN University of Salford
Faculty of Business Management and
Social Sciences Ellen Harper, MBA, RN
Health Informatics Research Group Senior Director, CNO Lighthouse
University of Applied Sciences Osnabrueck Cerner Corporation

Joanne Foster, GradDipCIEdn, MEdTech, Marceline Harris, PhD, RN

DipAppSc (NsgEd), BN, RN Nurse Administrator and Senior Associate
School of Nursing Consultant
Queensland University of Technology Department of Nursing and Health Sciences
Research
Yoadis Cuesta Garcia, Master of Science Mayo Clinic
in Health Informatics, Teacher in Health
Informatics, BSN, BCN Colleen M. Hart, MS, RN
Department of Health, Education Research Assistant/PhD Student
Cybernetics Center Applied to Medicine School of Nursing
(CECAM) University of Minnesota
viii Nursing and Informatics for the 21st Century, Second Edition

Kristiina Hayrinen, MSc Melinda J. Jenkins, PhD, RN, FNP

Researcher Consultant, Primary Care and Consumer
Department of Health Policy and Informatics
Management
University of Kuopio Luis Cibanal Juan, PhD, BPsy, RN
Cateobatico – Escuela Universitaria
Maria Heimisdóttir, PhD, MD, MBA Enfermeria en Salud Mental
Director Universidad de Alicante
Division of Economics, Budgeting and
Information Alain Junger, MPA, RN
Landspitali University Hospital Department of Nursing Administration
CHUV
Michelle LL Honey, PhD, MPhil (Nursing),
RN, FCNA (NZ) Premarani Kannusamy, PhD, RN
School of Nursing Department of Nursing
University of Auckland Institute of Mental Health

Mary L. Hook, PhD, RN, PHCNS-BC Karlene M. Kerfoot, PhD, RN, NEA-BC,
Research Scientist FAAN
System Nursing Research Vice President and Chief Clinical Officer
Aurora Health Care Department of Administration
Aurora Health Care
Derek Hoy, MSc, BSc
SnowCloud Karolyn Kerr, PhD Information Systems,
MHSc, RN
Ursula Hübner, PhD Informatics Consult
Professor
Department of Business Management and Rosaleen Killalea, MSc Nursing, BNS, RN
Social Sciences Department of Information Management
University of Applied Sciences Services
Mater Misericordiae University Hospital
Susan C. Hull, MSN, BSN, RN
Vice President, Business Strategies Hyeoneui Kim, PhD, MPH, BSN, RN
Clinical Practice Model Resource Center Informatician
Elsevier UCSD

Susan I. Hyndman, EdD, RN Tae Youn Kim, PhD

Chair, Non-Traditional Nursing Assistant Professor
Department College of Nursing
Director, RNI BS Nursing Program University of Wisconsin-Milwaukee
School of Nursing
College of St. Scholastica Pirkko Kouri, PhD, PHN, RN
Principal Lecturer
Helena Ikonen, MSc Department of Health Professions, Kuopio
Project Manager Savonia University of Applied Sciences
Laurea University of Applied Sciences
Margaret Ross Kraft, PhD, RN
Rafat Jan, PhD, RN Assistant Professor
School of Nursing Niehoff School of Nursing
Aga Khan University Karachi Loyola University Chicago
Contributors ix

Arusa Lakhani, MScN, BScN, RN, RM Heimar De Fatima Marin, PhD, MS, RN,
Senior Instructor FACMI
School of Nursing Professor
Aga Khan University Department of Nursing
Federal University of Sao Paulo
Norma M. Lang, PhD, RN, FAAN, FRCN
Wisconsin Regent Distinguished Professor Sana Daya Marini, PhD(c), BSN, BS, RN,
Aurora Distinguished Professor of HCC
Healthcare Quality Informatics Clinical Assistant Professor
College of Nursing School of Nursing
University of Wisconsin-Milwaukee American University of Beirut

Laura Heermann Langford, PhD, RN Anna Rita Marucci, MsNs, BaNsc, RN

Director, Nursing Informatics Head Nurse
Department of Medical Informatics Pediatric and Hemhatology Pediatric Ward
Intermountain Healthcare San Cahillo – Forlanini Hospital – Rome

Martin LaVenture, PhD, MPH Susan Matney, MSN, RN

Director Senior Content Engineer
Center for Health Informatics Department of Health Sciences IT
Minnesota Department of Health University of Utah

Carlos Hugo Leonzio, PhD(c), BSN Nagendra Prakash Mattur, PhD, MA,
Department of Education and Research M.Phil
Favaloro Foundation – University Hospital Professor
Manipal Institute of Management
Nancy M. Lorenzi, PhD, MS, MA, AB, Manipal University
FACMI
Assistant Vice Chancellor for Health Affairs Angela Barron McBride, PhD, RN, FAAN
Informatics Center Distinguished Professor-University Dean
Vanderbilt University Medical Center Emerita
School of Nursing
Sally P. Lundeen, PhD, MSN, BSN, RN, Indiana University
FAAN
Dean and Professor Mary N. Meyer, MSN, RN
College of Nursing Assistant Professor, Director of Clinical
University of Wisconsin-Milwaukee Learning Laboratory
School of Nursing
Merete Lyngstad, MSN, RN University of Kansas
Special Adviser
Department of Policy Issues Susan Meyer, B.Soc.Sci (Nursing) Diploma
Norwegian Nurses Organisation Paediatrics

Shirley Eichenwald Maki, MBA, RHIA, Kathryn Møelstad, RN

FAHIMA Senior Adviser
Assistant Professor Department of Policy Issues
Department of Healthcare Informatics and Norwegian Nurses Organisation
Information Management
The College of St. Scholastica David N. Mohr, MD, FACP
Chair, Information Technology Committee
John Mantas, PhD, MSc, BSc (Hons), Department of Internal Medicine
Professor Mayo Clinic
Faculty of Nursing
University of Athens
x Nursing and Informatics for the 21st Century, Second Edition

Erika Mayela Caballero Munoz, MEd Rutja Phuphaibul, DNS, RN

Instructional Design, RN-BC Professor
Dean Department of Nursing, Faculty of
San Sebastián University Nursing School Medicine
Vice President Ramathibodi Hospital, Mahidol University
Virtual Community of Infantile Health
Treasurer Ratna Prakash, PhD, MSc, BSc, BScN, PG
Chilean Health Informatics Association DH.Ed
Dean and Professor
Judy Murphy, BSN, RN College of Nursing
Vice President, Information Services Manipal University
Aurora Health Care
Vesna Prijatelj, MSc, RN
Peter J. Murray, PhD, MSc, RN Consultant Director in the Field of
Director and Founding Fellow Organization and Informatics
Centre for Health Informatics Research and Department of Managament
Development (CHIRAD) General Hospital Celje

Lynn M. Nagle, PhD, MScN, BN, RN David Printy, MS

Assistant Professor President and CEO
Laurence S. Bloomberg Faculty of Nursing Oasis Hospital
University of Toronto
Patricia Pruden, RN
Nancy C. Nelson, MS, BSN, RN Nurse Consultant
Data Manager Children’s Cancer Hospital Egypt
Intensive Medicine Clinical Program Foundation 57357
Intermountain Healthcare
Elina Rajalahti, MNSc
Elina Ora-Hyytiainen, PhD, MNSc, RN Senior Lecturer
Principal Lecturer Department of Social Services, Health and
Laurea University of Applied Sciences Sports
Laurea University of Applied Sciences
Mary E. Paden, MSN, RN, CPNP
TIP-NEP Program Coordinator Sripriya Rajamani, PhD, MBBS, MPH
School of Nursing Senior Project Consultant
Duke University Center for Health Informatics
Minnesota Department of Health
Hyeoun-Ae Park, PhD, RN
Associate Dean and Professor Uroš Rajkovič, MSc
College of Nursing Faculty of Organizational Sciences
Seoul National University University of Maribor

Filipe Suares Pereira, ND (PhD), MNSc, Vladislav Rajkovič, PhD

BN, RN Professor
Associate Professor Faculty of Organizational Sciences
Oforto College of Nursing University of Maribor

Heloísa Helena Ciqueto Peres Roberto A. Rocha, PhD, MD

Professor Doutor Senior Corporate Manager, Knowledge
Orientacao Profissional – ENO Management and Clinical Decision
Escola de Enfermagem da USP Support
Department of Clinical Informatics
Research and Development (CIRD)
Partners HealthCare System, Inc.
Contributors xi

April J. Roche, MBA, CPEHR Deirdre M. Stewart, Dip HCI, RGN, RPN
Project Manager Healthcare Executive
Center for Health Informatics Cerner Middle East
School of Nursing
University of Kansas Heather Strachan, MSc, MBCS, Dip. N,
RGN
Julita Sansoni, PhD, MScN, RN Clinical eHealth Lead (NMAHP)
Professor eHealth Directorate
Nursing Area Department of Public Health Scottish Government
University “Sapienza” of Rome
Amarnath Subramanian, MD, MS
Kaija Saranto, PhD, RN Medical Director, Pathology Informatics
Professor Department of Pathology and Lab Medicine
Department of Health Policy and Regions Hospital
Management
University of Kuopio Olga Šušteršič, PhD, RN
Associate Professor
Bjoern Sellemann, Dipl.-Pflegewirt, RN Department of Nursing, Faculty of Health
Faculty of Business Management and Social Sciences
Sciences University of Ljubljana
Health Informatics Research Group
University of Applied Sciences Osnabrueck Francesco Tarantini, MSN, BSN, RN
Dott.
Joyce Sensmeier, MS, RN-BC, CPHIMS, Transplant Operating Theatre
FHIMSS Fondazione IRCCS Ospedale Maggiore
Vice President, Informatics Policlinico, Mangiagalli e Regina Elena
Healthcare Information and Management
Systems Society Teri L. Thompson, PhD(c), RN, CPNP
Director, Pediatric Nurse Practitioner
Walter Sermeus, PhD, RN Program
Professor School of Nursing
School of Public Health University of Missouri-Kansas City
Catholic University Leuven
Asta Thoroddsen, PhD(c), MSc, RN
Abel Paiva e Silva, ND (PhD), MNSc, Associate Professor and Academic Chair of
BN, RN Nursing Informatics
Coordinator Professor Department of Nursing
Oporto College of Nursing University of Iceland and Landspitali Uni-
versity Hospital
Denise Tolfo Silveira, PhD, MS, RN
Professor Jane A. Timm, MS, RN
School of Nursing Informatics Nurse Specialist
Federal University of Rio Grande do Sul Department of Nursing
(UFRGS) Mayo Clinic

Roy L. Simpson, RN,C, DPNAP, FAAN Barbara S. Turner, DNSc, RN, FAAN
Vice President, Nursing Professor
Cerner Corporation School of Nursing
Duke University
Diane J. Skiba, PhD, FAAN
Professor and Coordinator of the Health Catherine E. Vanderboom, PhD, RN
Informatics Specialty Clinical Nurse Researcher
Department of Nursing Department of Nursing
University of Colorado Denver Mayo Clinic
xii Nursing and Informatics for the 21st Century, Second Edition

Irene van Middelkoop, Hons. BA(Cur) Lucy Westbrooke, GDipBus (Health

CAPRISA Informatics), DipNg, RCpN
University of KwaZula-Natal Department of Information Management
and Technology Services
Elmarie Venter, Mcom (Informatics), Bcur Auckland District Health Board
SAP Research, Pretoria
Bonnie L. Westra, PhD, RN, FAAN
Philipp Vetter, PhD Assistant Professor
Head of Strategy School of Nursing
Health Authority of Abu Dhabi University of Minnesota
Kanittha Volrathongchai, PhD (Nursing), RN Peggy White, MN, BA, RN
Assistant Professor National Project Director
Faculty of Nursing Canadian Health Outcomes for Better
KhonKaen University Thailand Information
Canadian Nurses Association
Janelle Wapola, MA, RHIA Care Project and Program Manager
Assistant Professor Health Outcomes for Better Information
Department of Healthcare Informatics and and Care
Information Management Ontario Ministry of Health and Long-Term
The College of St. Scholastica Care
Judith J. Warren, PhD, RN-BC, FAAN, Barbara J. Wills
FACMI Assistant Director
Christine A. Hartley Centennial Professor Division of Health Policy
and Director of Nursing Informatics, Minnesota Department of Health
Center for Health Informatics
School of Nursing Marty Witrak, PhD, RN, FAAN
University of Kansas Professor and Dean
School of Nursing
Tera J. Watkins, MS, RN The College of St. Scholastica
Senior Solution Designer, Lighthouse
Cerner Corporation

John M. Welton, PhD, RN

Associate Professor
College of Nursing
Medical University of South Carolina
Dedication
This is for those life-long friends who have stayed in my life throughout the decades—Gail
Mitchell, Ann Schmella and Mikelle Streicher—they are treasures beyond all measure. And as
always—to my son, Kevin Kauth.

— Charlotte A. Weaver

To my family who unselfishly supports my professional focus and giving of time—especially

son Jeremy & Jessica and granddaughters Ashley, Aana, Skye, & Storme Jade; Betty White,
Sue, E. Clark, Lora & Randy, Loren & Wendy, Ann, and Chris and Pat; and my late father
and brother, E. N. and Craig.
— Connie White Delaney

To my ever-supportive family—my wife, Marie-France, and my daughters, Delphine and

Chloé, to all my friends and colleagues in Europe, and to Charlotte Weaver for having been a
very helpful support.
— Patrick Weber

To my supportive husband Peter for his understanding of the English language and to my
colleagues in Health Informatics New Zealand (HINZ).
— Robyn L. Carr

xiii
Acknowledgments
In preparing this book, we have incurred many debts. First and foremost, we would like to
express our appreciation to Mary Kelly and Becky Thompson for their tireless editing and
project management of the many moving parts that make up this book. Nancy Vitucci, our
HIMSS editor, has worked through weekends and holidays burning the midnight oil with us
as we have all pushed to narrow the window between authors’ completion and time to print.
From conception to “book on the street,” this second edition has been produced in less than
two years. This accomplishment is due primarily to HIMSS’ commitment to supporting this
body of work and demonstrated through the hard work of Mary, Becky and Nancy. To all
three of you, we bow our heads in thanks!
Fran Perveiler, chief editor at HIMSS, is due our deep appreciation for having the vision
and courage to publish this second edition just four years after the first edition. Fran recog-
nized immediately the importance of continuing to capture the seismic changes that are hap-
pening in nursing, as countries’ adoption of EHR technologies accelerates.
And finally, Charlotte Weaver would like to express her gratitude to her employer, Gentiva
Health Services, for supporting this book initiative when, for all apparent purposes, it would
not appear to have much relevancy to a U.S. home healthcare organization.

Charlotte A. Weaver
Connie White Delaney
Patrick Weber
Robyn L. Carr
Editors

xv
Table of Contents

Foreword by Edward H. Shortliffe, MD, PhD ....................................................................xxiii

Preface ............................................................................................................................... xxv

SECTION I
Revolutionizing Nursing: Technology’s Role
Section I Introduction—Charlotte A. Weaver, PhD, MSPH, RN, FHIMSS ............................3
CHAPTER 1. Informatics and the Future of Nursing Practice ....................................................5
Angela Barron McBride, PhD, RN, FAAN
CHAPTER 2. TIGER: Technology Informatics Guiding Educational Reform—
A Nursing Imperative............................................................................................................17
Donna B. DuLong, BSN, RN; and Marion J. Ball, EdD, FACMI, FCHIME, FHIMSS, FAAN
CHAPTER 3. Informatics for Personal Health Management ....................................................25
Melinda J. Jenkins, PhD, FNP; Pirkko Kouri, PhD, PHN, RN;
and Charlotte A. Weaver, PhD, MSPH, RN, FHIMSS
CHAPTER 4. International Initiatives in Nursing Informatics...................................................45
Heimar De Fatima Marin, PhD, MS, RN, FACMI;
and Nancy M. Lorenzi, PhD, MS, MA, AB, FACMI
CHAPTER 5. Growth in Nursing Informatics Educational Programs to Meet Demands ............53
Diane J. Skiba, PhD, FAAN; Helen R. Connors, PhD, DrPS (Hon), RN, FAAN;
and Michelle LL Honey, PhD, MPhil (Nursing), RN, FCNA (NZ)
CHAPTER 6. The Impact of Health Information Technology (I-HIT) Survey:
Results from an International Research Collaborative............................................................69
Patricia C. Dykes, DNSc, MA, RN; Suzanne Brown, MSc Health Informatics, BNS;
Rita W. Collins, PhD, MEd, BNS, RN, RM; Robyn Cook, MBA, BBus, RN;
Charles Docherty, PhD, MN, MBCS, BN, RN, RNT; Anneli Ensio, PhD, RN;
Joanne Foster, GradDipCIEdn, MEdTech, DipAppSc (NsgEd), BN, RN;
Nicholas R. Hardiker, PhD, RN; Michelle LL Honey, PhD, MPhil (Nursing), RN, FCNA (NZ);
Rosaleen Killalea, MSc Nursing, BNS, RN; and Kaija Saranto, PhD, RN

SECTION II
Nursing Education and IT
Section II Introduction—Connie White Delaney, PhD, RN, FAAN, FACMI..........................91
CHAPTER 7. Faculty Competencies and Development..............................................................93
Helen R. Connors, PhD, DrPS (Hon), RN, FAAN
Case Study 7A. University of Pittsburgh—Faculty Development Program:
Emerging, Learning, and Integrated Technologies Education (ELITE) .......................... 104
Helen K. Burns, PhD, MN, BSN, RN, FAAN; and Karen L. Courtney, PhD, RN
Case Study 7B. University of Kansas School of Nursing—Faculty
Development Program: Health Information Technology Scholars (HITS) ..................... 110
Helen R. Connors, PhD, DrPS (Hon), RN, FAAN

xvii
xviii Nursing and Informatics for the 21st Century, Second Edition

Case Study 7C. Technology Integration Program for Nursing Education

and Practice (TIP-NEP)............................................................................................... 118
Barbara S. Turner, DNSc, RN, FAAN; and Mary E. Paden, MSN, RN, CPNP
Case Study 7D. Health Informatics and Continuing Education: The Italian Case .......... 123
Julita Sansoni, PhD, MScN, RN; Anna Rita Marucci, MsNs, BaNsc, RN;
Francesco Tarantini, MSN, BSN, RN; and Walter De Caro, MNs, DAI
CHAPTER 8. Informatics Competencies for Nurses Across Roles and
International Boundaries .................................................................................................... 129
Brian Gugerty, DNS, MS, RN; and Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS
CHAPTER 9. Transforming Nursing Education: Integrating Informatics and Simulations ....... 145
Judith J. Warren, PhD, RN-BC, FAAN, FACMI; Mary N. Meyer, MSN, RN;
Teri L. Thompson, PhD(c), RN, CPNP; and April J. Roche, MBA, CPEHR
Case Study 9A. The ATHENS Project: Advancing Technology in
Healthcare Education Now at St. Scholastica ............................................................... 162
Shirley Eichenwald Maki, MBA, RHIA, FAHIMA; Marty Witrak, PhD, RN, FAAN;
Sally K. Fauchald, PhD, RN; Beth A. Donahue, MA, BAN, RN-BC;
Susan I. Hyndman, EdD, RN; and Janelle Wapola, MA, RHIA
Case Study 9B. Learning by Developing ........................................................................ 169
Elina Ora-Hyytiäinen, PhD, MNSc, RN; Helena Ikonen, MSc; Outi Ahonen, MNSc;
Elina Rajalahti, MNSc; and Kaija Saranto, PhD, RN

Section III
Innovation Through Applied Informatics
Section III Introduction—Patrick Weber, MA, RN............................................................. 177
CHAPTER 10. Use of Data by Nursing to Make Nursing Visible:
Business and Efficiency of Healthcare System and Clinical Outcomes ................................. 179
John M. Welton, PhD, RN; and Walter Sermeus, PhD, RN
Case Study 10A. Standardizing the Electronic Nursing Summary:
Motivation, Methods, and Results ................................................................................. 193
Ursula Hübner, PhD; and Daniel Flemming, Dipl. Kaufmann, RN
Case Study 10B. Improving Patient Safety, Increasing Nursing Efficiency,
and Reducing Cost through Technology-Supported Pull Systems ................................... 200
Thomas R. Clancy, PhD, MBA, RN; and Susan C. Hull, MSN, BSN, RN
CHAPTER 11. ICNP®: Nursing Terminology to Improve Healthcare Worldwide .................... 207
Amy Coenen, PhD, RN, FAAN; and Claudia Bartz, PhD, RN, FAAN
Case Study 11A. A Process for Standardizing Documentation Contents
for Electronic Documentation Systems .......................................................................... 217
Hyeoneui Kim, PhD, MPH, BSN, RN; Patricia C. Dykes, DNSc, MA, RN;
and Roberto A. Rocha, PhD, MD
CHAPTER 12. Building an Intelligent Clinical Information System for Nursing:
The Aurora, Cerner, and University of Wisconsin, Milwaukee, Knowledge-based
Nursing Initiative—Part II ................................................................................................. 225
Karlene M. Kerfoot, PhD, RN, NEA-BC, FAAN; Sally P. Lundeen, PhD, MSN, BSN, RN,
FAAN; Ellen Harper, MBA, RN; Norma M. Lang, PhD, RN, FAAN, FRCN; Laura J. Burke,
PhD, RN, FAAN; Mary L. Hook, PhD, RN, PHCNS-BC; Judy Murphy, BSN, RN; Elizabeth
C. Devine, PhD, MSN, RN; Tae Youn Kim, PhD; Andrew F. Carlson, BS Systems Analysis;
Jennifer Conner, BA; and Tera J. Watkins, MS, RN
Table of Contents xix

Case Study 12A. The USA National Veterans Administration

Clinical Information System ......................................................................................... 242
Margaret Ross Kraft, PhD, RN
Case Study 12B. Canadian Health Outcomes for Better Information
and Care (C-HOBIC) ................................................................................................... 247
Kathryn J. Hannah, PhD, RN; and Peggy White, MN, BA, RN
CHAPTER 13. International Standards to Support Better Information Management .............. 253
Nicholas R. Hardiker, PhD, RN; Suzanne Bakken, DNSc, RN, FAAN, FACMI;
William T.F. Goossen, PhD, RN; Derek Hoy, MSc, BSc; and Anne Casey, MSc, RN, FRCN
Case Study 13A. Application of iNMDS using ICNP® ................................................. 262
Bonnie L. Westra, PhD, RN, FAAN; William T.F. Goossen, PhD, RN;
Lynn M. Choromanski, MS, RN; Beverly J. Collins, MS, RN;
Colleen M. Hart, MS, RN; and Connie White Delaney, PhD, RN, FAAN, FACMI
Case Study 13B. Update of the NMMDS and Mapping to LOINC .............................. 269
Bonnie L. Westra, PhD, RN, FAAN; Susan Matney, MSN, RN;
Amarnath Subramanian, MD, MS; Colleen M. Hart, MS, RN;
and Connie White Delaney, PhD, RN, FAAN, FACMI
Case Study 13C. Nursing Quality Measures: National Database of
Nursing Quality Indicators® ......................................................................................... 276
Nancy E. Dunton, PhD

SECTION IV
EHR Initiatives Across the Globe
Section IV Introduction—Robyn L. Carr, RGON ............................................................... 283
CHAPTER 14. The Americas: Overview of EHR National Strategies and
Significance for Nursing...................................................................................................... 285
Lynn M. Nagle, PhD, MScN, BN, RN; Heimar De Fatima Marin, PhD, MS, RN, FACMI;
and Connie White Delaney, PhD, RN, FAAN, FACMI
Case Study 14A. Canada’s Journey Toward an Electronic Health Record:
Nursing’s Role .............................................................................................................. 294
Lynn M. Nagle, PhD, MScN, BN, RN; and Peggy White, MN, BA, RN
Case Study 14B. Mayo Clinic ....................................................................................... 300
Marceline R. Harris, PhD, RN; David N. Mohr, MD, FACP; Jane A. Timm, MS, RN;
Catherine E. Vanderboom, PhD, RN; and Scott W. Eising, BS
Case Study 14C. Intermountain Healthcare .................................................................. 306
Laura Heermann Langford, PhD, RN; and Nancy C. Nelson, MS, BSN, RN
Case Study 14D. Minnesota Statewide e-Health Initiative ............................................. 312
Bonnie L. Westra, PhD, RN, FAAN; Martin LaVenture, PhD, MPH; Barbara J. Wills;
and Sripriya Rajamani, PhD, MBBS, MPH
Case Study 14E. Redirecting the Development of the Electronic
Registry for Nursing in Cuba ........................................................................................ 323
Yoadis Cuesta Garcia, MS Health Informatics, Teacher in Health Informatics, BSN, BCN
Case Study 14F. A Historical Account and Current Status of
Nursing Informatics in Argentina .................................................................................. 332
Carlos Hugo Leonzio, PhD(c), BSN; and Cristina Barrios, BSN
Case Study 14G. Brazil ................................................................................................. 337
Grace T.M. Dal Sasso, Nursing Informatics PhD, RN; Denise Tolfo Silveira, PhD, MS, RN;
Heloísa Helena Ciqueto Peres; and Heimar De Fatima Marin, PhD, MS, RN, FACMI
xx Nursing and Informatics for the 21st Century, Second Edition

Case Study 14H. The Electronic Health Record in Chile ............................................... 343
Erika Mayela Caballero Muñoz, MEd Instructional Design, RN-BC
CHAPTER 15. Information Technology Strategies in the United Kingdom and Ireland ........... 347
Anne Casey, MSc, RN, FRCN
Case Study 15A. Ireland ............................................................................................... 358
Rita W. Collins, PhD, MEd, BNS, RN, RM;
and Rosaleen Killalea, MSc Nursing, BNS, RN
Case Study 15B. Northern Ireland’s Information and Communications
Technology Strategy: A Case Study of Nursing Activity................................................ 363
Mary Chambers, PhD, BED(Hons); and Claire Buchner, MSc Health Informatics, BSc
(Hons) Nursing Studies
Case Study 15C. Clinical eHealth Lead (NMAHPs), Scotland...................................... 369
Heather Strachan, MSc, MBCS, Dip.N, RGN
CHAPTER 16. Electronic Health Initiatives: European View .................................................. 375
Patrick Weber, MA, RN; and John Mantas, PhD, MSc, BSc(Hons)
Case Study 16A. The Development and Implementation of the EHR in Iceland ............. 382
Asta Thoroddsen, PhD(c), MSc, RN; Herdís Gunnarsdóttir, MSc, MBA, BSc, RN;
and Maria Heimisdóttir, PhD, MD, MBA
Case Study 16B. Finland’s National EHR ..................................................................... 389
Kristiina Häyrinen, MSc; Pirkko Kouri, PhD, PHN, RN; and Kaija Saranto, PhD, RN
Case Study 16C. National Leadership in eHealth: The Norwegian Case ........................ 397
Kathryn Møelstad, RN; and Merete Lyngstad, MSN, RN
Case Study 16D. Development of Health Informatics to Support
Nursing Care in Sweden ................................................................................................ 404
Margareta Ehnfors, PhD, Dipl NEd, RN; and Anna Ehrenberg, PhD, RN
Case Study 16E. The Netherlands: Virtual Electronic Health Records
Based on Safe Data Exchange ...................................................................................... 412
William T.F. Goossen, PhD, RN; A.T.M. Goossen-Baremans, MSN, RN; and Lejo Bouma, RN
Case Study 16F. Toward Integrating Nursing Data into the
Electronic Patient Record: Current Developments in Germany ...................................... 421
Ursula Hübner, PhD; Bjöern Sellemann, Dipl. Pflegewirt, RN;
and Daniel Flemming, Dipl. Kaufmann, RN
Case Study 16G. Spain: The Growth and Development of Nursing and
Information Systems—An Update from 2006 to 2009.................................................... 429
Myriam Martin Fernández, PhD, MSN, RN; and Luis Cibanal Juan, PhD, BPsy, RN
Case Study 16H. Information Technologies and Nursing Practice:
The Portuguese Case .................................................................................................... 435
Filipe Suares Pereira, ND (PhD), MNSc, BN, RN; and Abel Paiva e Silva, ND (PhD),
MNSc, BN, RN
Case Study 16I. Nursing and Informatics Past, Present, and Future in Switzerland ....... 442
Alain Junger, MPA, RN
Case Study 16J. Reengineering of Nursing Process: e-Documentation Case................... 447
Vesna Prijatelj, MSc, RN; Uroš Rajkovič, MSc; Olga Šušteršič, PhD, RN;
and Vladislav Rajkovič, PhD
CHAPTER 17. Healthcare Information Technology and Electronic Health Records:
A View from the Middle East .............................................................................................. 455
Roy L. Simpson, RN,C, DPNAP, FAAN; and Deirdre M. Stewart, Dip HCI, RGN, RPN
Case Study 17A. Israeli Healthcare .............................................................................. 459
Ayala Gonen, PhD, RN
Table of Contents xxi

Case Study 17B. Lebanon/Beirut Healthcare ................................................................ 465

Sana Daya Marini, PhD(c), BSN, BS, RN, HCC
Case Study 17C. United Arab Emirates (UAE) Healthcare ........................................... 472
David Printy, MS; Philipp Vetter, PhD; and Kelly Marie Damon, MAL, BSN, RN
Case Study 17D. The EHR Initiatives in Turkey ........................................................... 477
Firdevs Erdemir, PhD, RN
Case Study 17E. Challenge, Change, Hope, Excellence-Oriented:
Children’s Cancer Hospital Egypt 57357—Icon of Change............................................ 482
Patricia Pruden, RN
CHAPTER 18. Nursing Informatics in South Africa: From a Historical Overview
to the Emergence of EHRs, Telehealth, and m-Health......................................................... 491
Peter J. Murray, PhD, MSc, RN; Irene van Middelkoop, Hons. BA (Cur); Elmarie Venter,
Mcom (Informatics), Bcur; and Susan Meyer, B.Soc.Sci (Nursing) Dipl. Paediatrics
CHAPTER 19. Nursing and the Electronic Health Record in Asia, Australasia,
and the South Pacific .......................................................................................................... 505
Karolyn Kerr, PhD Information Systems, MHSc, RN; and Polun Chang, PhD
Case Study 19A. The Nursing Informatics Renaissance in Taiwan ................................. 517
Polun Chang, PhD
Case Study 19B. Current Status and Evolution of Nursing Informatics
in South Korea .............................................................................................................. 524
Hyeoun-Ae Park, PhD, RN; and Insook Cho, PhD
Case Study 19C. Nursing and the EHR in Thailand ...................................................... 532
Kanittha Volrathongchai, PhD (Nursing), RN; and Rutja Phuphaibul, DNS, RN
Case Study 19D. Australia: Developing the Electronic Health Record,
A Continuing Nursing Challenge................................................................................... 535
Robyn Cook, MBA, BBus, RN; and Joanne Foster, GradDipCIEdn, MEdTech, DipAppSc
(NsgEd), BN, RN
Case Study 19E. The New Zealand Approach to the Electronic Health Record .............. 541
Lucy Westbrooke, GDipBus (Health Informatics), DipNg, RCpN
Case Study 19F. Electronic Health Record National Strategies and
Significance for Nursing (Singapore) ............................................................................. 548
Premarani Kannusamy, PhD, RN
Case Study 19G. Health and Nursing Informatics in Indian Context:
A Futuristic Perspective of e-Healthcare ....................................................................... 556
Ratna Prakash, PhD, MSc, BSc, BScN, PG DH.Ed; and Nagendra Prakash Mattur, PhD,
MA, M.Phil
Case Study 19H. Health and Nursing Information Technology:
A Case Study of Pakistan ............................................................................................. 566
Rafat Jan, PhD, RN; Arusa Lakhani, MScN, BScN, RN, RM; and Nighat Ijaz Durrani,
MPH(PAK), Dip in Administration & Teaching, Opthlamic Nursing UK, RN, RM

Section V
The Near Future and Nursing
Section V Introduction—Charlotte A. Weaver, PhD, MSPH, RN, FHIMSS....................... 573
CHAPTER 20. Nursing and Nursing Informatics: Current Context to Preferred Future .......... 575
Charlotte A. Weaver, PhD, MSPH, RN, FHIMSS; Connie White Delaney, PhD, RN, FAAN,
FACMI; Patrick Weber, MA, RN, and Robyn L. Carr, RGON
Index .................................................................................................................................. 595
Foreword
Those of us who have been involved with biomedical and health informatics for most of our
professional lives are amazed and gratified by the growing recognition, support, and enthu-
siasm for our field. The pace of change has been particularly remarkable in the last decade,
spurred on in the United States by a Secretary of Health and Human Services, Tommy
Thompson, who made health information technology (IT) a key element in his strategy for
addressing the problems with the U.S. healthcare system. Reflected also in frequent comments
by President George W. Bush, support for health IT innovation and investment became even
more evident in the administration of President Barack Obama, who worked with Congress to
make health IT a key element in the American Recovery and Reinvestment Act of 2009. The
Office of the National Coordinator for Health Information Technology (ONC), now formally
codified in law, has new leadership and a large stimulus budget to invest heavily in a variety of
programs intended to enhance the adoption, “meaningful use,” and acceptance of electronic
health records and related components of the health information infrastructure. Recogniz-
ing the dearth of trained professionals who understand both the technology and the cultural
milieu into which health IT must be introduced, ONC is also investing in a variety of work-
force development programs, ranging from certification courses and validation of competen-
cies to degree programs in universities and professional schools.
Throughout the evolution of our field, the nursing community has provided remarkable
leadership in defining the role of informatics in the nursing profession, in bringing informatics
knowledge to nursing practitioners, and in building an international community of nursing
educators and informaticians that has been a role model for the other health professions. The
first edition of this volume, appearing only four years ago, has been a stimulus to the cohe-
sion of the nursing community regarding informatics education, scholarship, and the effective
application of the field’s principles. Yet, as mentioned, those same four years have seen impres-
sive change in the societal interest and investment in health information technology, and thus,
it is now highly appropriate to update the volume with a second edition that reflects the current
momentum and investment. Nursing itself is evolving, in part due to what is happening in the
information management arena, and this volume reflects and enhances those changes as well.
As we pursue “meaningful use” of health information technology, a key element is clearly
the extent to which health professionals understand and embrace the role of such systems in
their work, while appreciating their limitations and the need for ongoing research and innova-
tion. No health profession has been as effective as nursing in bringing a knowledge of infor-
matics concepts and applications to the routine education of practitioners. Section II in this
volume describes key elements in such educational programs for nurses, including evolving
expectations, curricular components, and the competencies that graduates must demonstrate.
Other schools in the health professions have much to learn from the extensive experience and
success described in these pages.
But the rest of the book is inspiring as well. Using scenarios and case studies to make
the concepts concrete, the editors and chapter authors have nicely demonstrated the wide
ranging and international role that informatics is playing in nursing practice, as well as the
important contributions of nursing informatics innovation. Those of us who have attended
the triennial Nursing Informatics (NI) conferences (sponsored by the International Medi-
cal Informatics Association) can attest to the energy, enthusiasm, and accomplishment that
is routinely demonstrated in the scientific sessions and policy panels. It is small wonder that
an involvement with informatics is often identified as a key indicator of the intellectual rigor
and pragmatic orientation of the leaders in the nursing profession, whether in academia or in
practice settings.
xxiii
xxiv Nursing and Informatics for the 21st Century, Second Edition

This volume is also evidence of the recognized synergies between the American Medical
Informatics Association, the professional home for those in biomedical and health informat-
ics (including a strong component representing the nursing informatics community), and the
Healthcare Information and Management Systems Society (HIMSS), the membership orga-
nization that focuses on providing global leadership for the optimal use of health IT. We at
AMIA are delighted to be collaborating with HIMSS on the co-publication of the second edi-
tion of a volume that we know will continue to inform and inspire a generation of nurses and
other professionals who turn to nursing for examples of excellence in informatics education,
scholarship, and application.

— Edward H. Shortliffe, MD, PhD

President and Chief Executive Officer
American Medical Informatics Association
Bethesda, MD USA
Preface
Since the publication of this book’s first edition in 2006, the fundamentals set out in the pref-
ace have not changed. Governments still struggle to balance available funding against opti-
mum quality care, as evidence of value for money spent. Many governments, ever challenged
to place funding for health against financial demands from education, social welfare infra-
structure and, for some, defense, find additional squeezing of their budgets. This financial
imperative brings with it a greater need for enhanced technical support in cross-discipline
communications and care options to enhance quality, safety, access, and efficiency.
What has notably changed is that nursing informatics per se, originally with European and
American initiatives, is now being practiced in an ever increasing number of countries on the
Asian, Australasian, South American and African continents, although firm evidence of the
latter is sparse. Therefore, in this edition, we have attempted to embrace qualitative evidence
from a number of the more recent sources of informatics practices in the countries entering
into the wider group. While some of these new entrants may be perceived to be in the embry-
onic stage of advancement, there is a common theme—the basic education of nurses must
include informatics competencies and the capacity to prepare informatics specialists.
While this second edition has substantial changes in the content covered in comparison to
the first edition, the essence of the international “snapshot” of current state remains the same.
These past four years have brought such rapid change in information and communication
technologies, governments’ IT strategies and their implementations, that we felt it was impera-
tive to capture the state of nursing internationally as we go into the second decade of the 21st
century. Major geopolitical changes have also occurred over these intervening years. China
and India have emerged on the international stage as major economic and geopolitical powers.
The health indicators of both countries show a rapid ascent that parallels their economic rise
and gains in standards of living. And importantly, the health indicators of China and India
are now matching those of EU countries, indicating their full emergence status. While India is
represented in the country case studies and Taiwan has been added, we were not able to secure
a contributor from mainland China. This omission reflects a lack of professional integration
with our Chinese counterparts through international collaborations such as the International
Medical Informatics Association (IMIA). It is through the editors’ networks made possible by
IMIA-NI that the majority of authors have been recruited for this book. Given that together
China and India’s citizens account for about 2.5 billion of the world’s near 7 billon popula-
tion,1 we recognize that any international trend analysis without both of these superpowers
included is seriously remiss.
This second edition book is organized into five sections, and while it has a heavy U.S.
perspective, each section and most chapters have international content and authors. Section I
carries the same title as in the first edition: “Revolutionizing Nursing: Technology’s Role.”
Dr. Angela McBride’s opening Chapter 1 provides a penetrating overview of how extensively
informatics has already permeated nursing practice in the United States. Dr. McBride poses
the question to professional nursing as to how we will use the quantitative nursing data that
emanates from EHR systems. Dr. McBride notes that EHR systems and their data allow nurs-
ing’s contribution to outcomes to be visible for the first time in our history. The interesting
twist in Dr. McBride’s observations is that with this visibility comes accountability, and she
counsels: “It can be scary to get what you wished for, but, most of all, it can be enormously
energizing. Let us all move to seize the opportunities before us that will not come this way
again.” Dr. McBride’s chapter is a must read for all nurses regardless of role or country.
There are four additional strong chapters included in Section I. DuLong and Ball’s Chapter
2 is an up-to-date summary of the TIGER Collaborative, a grassroots initiative in the United
xxv
xxvi Nursing and Informatics for the 21st Century, Second Edition

States originally formed to address nursing workforce competencies and educational reforms.
In Chapter 3, Jenkins and colleagues address the emergence of person empowerment in self
management enabled by new Internet technologies and government health policies. In Chapter
4, Marin and Lorenzi use their long-standing leadership involvement in international informat-
ics circles to give an overview on key informatics initiatives currently in process. This is followed
by Skiba, Connors, and Honey in Chapter 5, who present a powerful description of nurs-
ing education, IT competencies needed in core curriculum and document the rapid growth in
nursing informatics programs occurring in different parts of the world. In the closing chapter,
Dykes and colleagues report on a three-year survey study looking at international comparisons
of nurses perspectives on the helpfulness of information technology in acute care settings.
Section II focuses on nursing education, including IT competencies in basic curriculum.
The new topic introduced here is a description of formal programs for nursing faculty devel-
opment in IT competencies being conducted in many countries today; the chapters and case
studies explore examples from Italy, Finland, and the United States. Section III is dedicated
to new developments in international standards for information management, terminologies,
and minimum data base sets. This section also includes an update from the University of Wis-
consin-Milwaukee, Aurora Health and Cerner Corporation’s research team on their 6+ year
project to develop and embed evidence-based nursing content into an automated nursing clini-
cal documentation system with the generation of nursing outcomes.
Section IV presents the international overview on the current state of nursing and adoption
of EHR technologies. Section IV entitled EHR Initiatives Across the Globe is the core of the
book, with 6 chapters representing the following geographic regions: The Americas, The United
Kingdom and Ireland, Europe, Middle East, South Africa, and Asia, Australasia, and the South
Pacific. There are 35 country case studies under these six geographic chapters. And, as men-
tioned above, we have been able to include a number of new areas and countries in this edition.
Chapter 17 focuses on the Middle East and includes case studies from Egypt, Israel, Lebanon,
the United Arab Emirates, and Turkey. In Europe, we have added Portugal and a contribution
from Slovenia for Eastern Europe. In Southeast Asia, we are very pleased to have been able to
include new case studies from Thailand, Singapore, and Pakistan, in addition to India.
The final section is a single chapter written by the four editors and presents an overview
on the current state of nursing and nursing informatics identifying common themes, structural
indicators in nursing status within a country, and correlation of educational levels to profes-
sional autonomy. We close this critique with a projected vision for the near future that includes
opportunities, challenges, and questions for nursing leaders to ponder.
This second version of Nursing and Informatics for the 21st Century is bringing brand new
contributions. Each author, empowered by the success of the first edition, has given his or her
best to provide the latest up-to-date information and to propose a realistic vision of the near
future of information and informatics in the field of health and nursing. This book affords the
widest view of the most recent developments in this field. The best known experts in the nurs-
ing informatics world have contributed to this volume. We hope it becomes one of your most
used, referenced, read, and reread books over these next years.

Charlotte A. Weaver
Connie White Delaney
Patrick Weber
Robyn L. Carr
Editors

Reference
1. Central Intelligence Agency. The World Fact-
book—China. https://www.cia.gov/library/
publications/the-world-factbook/geos/ch.html.
Accessed December 8, 2009.
SECTION I

Revolutionizing Nursing:
Technology’s Role

1
Exploring the Variety of Random
Documents with Different Content
 CHAPTER IX.
“Studying?” asked a woman’s voice outside my door. On returning
to my room, I took out one of the books I had brought, tied to my
tripod, and was reading it.
“Go right ahead, Sensei, don’t mind me,” said the voice before I
gave any answer, and its owner walked right into my room with no
conventionality whatever.
A shapely neck, looking all the more fair because of the subdued
colour of the part of kimono protecting its lower half, it was this
charming contrast that struck my eye, as the woman sat before me.
“A foreign book? Full of hardy, knotty problems, I suppose,
Sensei?”
“No, not quite.”
“Then, what is it all about?”
“Well, to be honest, I do not know well enough to tell you.”
“Ho, ho, ho, and yet you are studying?”
“I am not studying. I put it on the desk, open it at random, and
just skim the open page. That is all.”
“Does that sort of thing interest you?”
“Marvellously.”
“How?”
“How? Why, that is the most interesting way of reading novels.”
“You are so odd, Sensei.”
“Yes, I should say I am rather.”
“Why should you not read them from the beginning?”
 “If you begin to read from the beginning, you will have to read to
the end, don’t you see?”
“How absurdly you talk. There can be nothing wrong in reading
through a novel?”
“No, of course not. If it is to read the plot, I, also shall do so.”
“What else is there to read, if not the plot?”
She is after all a woman, I thought, and felt like testing her.
“Do you like novels?”
“I?” She made a pause after the word, and then said
ambiguously: “Well in a way.” She seemed not to care much about
novel-reading.
“Perhaps you are not sure yourself that you like or you do not like
reading-novels?”
“What difference does it make if one likes or not likes novels?”
Novels seemed to have no claim to existence in her mind.
“It would not matter, then, if one read them from the beginning
or from the end, or from any page one happened to open. I should
think, you need not be so curious about my way of reading.”
“But you and I are different.”
“In what way, please.” I looked into the woman’s eyes, thinking, I
was testing her. But they spoke nothing.
“Ho, ho, ho, you don’t see?”
“But you must have read a good many in your younger days?” I
made a little detour, instead of keeping straight to my point.
“I am still young—at least in heart—you unkind man.” The falcon I
let off was once more going astray to miss the prey: she would let
me have no chance. But I managed to bring her back on the track
by retorting: “Being able to say that sort of thing in the face of a
man, you must be counted among the not young.”
 “Arn’t you, who say that, also well up in age? And you mean to
say that you still delight in reading of love, Cupid and all that kind of
trash?”
“Yes, they are delightful and will not cease to interest me even till
my last hour.”
“Well I declare! That is how you can give yourself up to a
profession like yours, I suppose?”
“Precisely so. Because I am an artist, I have no need to read
through novels from the beginning to the end. But they interest me
no matter what part I read. It delights me to talk with you, so much
so that I should be glad to be all the time talking with you, while I
am here. If you would have it, I have not the slightest objection, on
my part, to falling incandescently, in love with you. That would be
most interesting. But, however intensely in love, there is no need
that we should become husband and wife. One must need read
through novels from the beginning to the end, as long as one feels
the necessity of love ending in a marriage.”
“The artist is, then, he who makes an inhuman love?”
“Not inhuman but unhuman. The plots of novels do not count at
all, because we read them unhumanly. You see, I open the book
thus, as in a lottery drawing, and I read the first page that lies flat
before me. And there is the charm of the thing.”
“That does sound interesting. Then I wish you would tell me
something of what you are reading. I should like to know how
interesting it really is.”
“To tell you would not do. Don’t you see, the charm of a picture
would all be gone, if you simply made a narration of it.”
“Ho, ho, ho, read it to me, then, please.”
“In English?”
“No, in Japanese.”
“It would be a job to read English in Japanese.”
 “It would be lovely, being so unhuman.”
A fun for the while, I thought, and began to read the book in
Japanese, with stops and pauses. If there was an unhuman way of
reading, mine was certainly it, and the woman was listening also
unhumanly.
“‘An aura of tenderness rose from the woman,—from her voice,
from her eyes, from her skin. The woman went to the stern helped
by the man. Did she go there to have a look at Venice, now
enshrouded in the evening dusk? And the man, did he help her to
feel lightning flashes in his blood on his side?’—Mind, it is all
unhuman, and don’t look for accuracy. I may make skips, too.”
“I won’t mind a bit, Sensei; you may add in something of your
own if you like.”
“‘The woman was leaning against the gunwale by the side of the
man, with a distance between them narrower than her ribbons,
which the wind was playing with. The Doge of Venice was now
vanishing in light red like the second sunset....’”
“What is the Doge, Sensei?”
“It doesn’t matter what that means. However, it is the name of
the man who long ago ruled over Venice. I don’t know how many
Doges succeeded one another. Anyhow their palace has outlived
them and may still be seen in Venice.”
“Who are that man and woman?”
“God only knows, and that is why it is so interesting. You need
not bother yourself about what their relations have been. I find them
together just like you and I here. There is something interesting,
don’t you see, just for the occasion?”
“As you please. They seem to be in a boat.”
“On land or in water, it is just as it is written. You will make a
detective of yourself, if you press for ‘why’.”
“Ho, ho, ho, I will not ask you then.”
 “Ordinary novels are all inventions of detectives and denuded of
unhumanity they are all so insipid.”
“Good, then, tell me more of unhumanity. What follows next,
please?”
“‘Venice is sinking, sinking to a faint single streak of line. The line
dwindles into dots. Here and there pillars stand in an opal sky, last of
all the highest towering belfry sinks. It has sunk, says the friend.
The woman, who has come away from Venice is free like the wind of
the sky in her heart. But the thought that she must come back to
Venice, which has disappeared, fills her heart with the anguish of
bondage. The man and woman direct their eyes toward the
darkening bay. The stars are increasing. The sea is softly undulating
without any foam. The man took the woman’s hand in his, feeling
like one holding a bow-string that has not yet stopped vibrating.’”
“That does not seem to sound very unhuman.”
“But you can hear it as unhuman. If you don’t like it, I shall skip a
little.”
“Oh, no, I am all right.”
“If you are all right, why, I am a great deal more all right. Now,
let me see—it is getting so bungling—it is so awkward to trans—I
mean, to read.”
“You may cut it out, if it be so bothering.”
“No, I shall go it rough—‘This one night, says the woman. One
night? asks the man. Say, many, many nights; it is heartless to limit
it to a single night.’”
“Who says that, the man or the woman?”
“The man, O-Nami-san, I think the woman does not want to go
back to Venice, and the man is saying this to console her—‘In the
memory of the man, who lay down on the midnight deck with his
head on a coil of halyard, that instant—an instant like a hot drop of
blood,—that instant in which he tightly held the woman’s hand in
his, tossed like a great wave. Looking up into the black night, he
resolved, come what may, to save the woman from the brink of
forced marriage. With his mind made up, he closed his eyes....’”
“The woman?”
“‘Lost on the road, the woman seemed not to know whither she
was wandering. Like a man sailing in the sky a captive,
unfathomable mystery....’—the rest is so awkward to read, you see,
it does not complete the sentence—‘only the unfathomable
mystery’—isn’t there any verb?”
“Never mind a verb. Sensei, you don’t want any verb; that is quite
enough.”
“Eh?”
All of a sudden a rumbling sound came, and all the trees on the
mountain spoke. We looked at each other, not knowing why, and
saw a solitary spray of camellia in a small vessel on my desk
swinging.
“An earthquake!” Nami-san brought herself right up against my
desk, with a break in her pose, as she said this, and our bodies were
oscillating, almost touching each other. A pheasant—a bird credited
with super-human sensitiveness for seismic phenomena—flew out of
the bamboo bush, making a sharp noise with the flapping of its
wings.
“A pheasant,” I said looking out of the window.
“Where?” said the woman with another break in her posture,
bringing herself closer to me. She was so near me that our heads
were almost in contact with each other. I felt on my moustaches
breaths coming out of her gentle nostrils.
“Remember, all unhumanity!” said the woman unequivocally as
she quickly corrected her pose.
“Of course,” I responded promptly.
 A pool of water in the hollow of a rock in the garden was
agitating in alarm; but that body of water moving from the very
bottom as a whole, there was no break in the surface but irregular
curves. If there be such an expression as moving “full roundly,” it
fitted exactly, I thought, the condition of this pool of water. A wild
cherry tree, which had its shadow cast peacefully in the pool, now
stretched out of all shape, now shrivelled up, then wriggled and
twisted. For all those contortions, it was most interesting to observe
that the tree never failed to appear the cherry tree it was.
“This is delightful. There is beauty and variation. Motion must be
of this sort to be interesting.”
“Man will be all right as long as his motion is of this sort, no
matter how hard he moves.”
“You cannot move like this unless you are unhuman.”
“Ho, ho, ho, how deeply in love you are with unhumanity, Sensei!”
“Nor can you deny that you are not without partiality for it, after
your bridal gown show yesterday?” I made a lunge.
She parried by saying sweetly with a coquettish smile: “A nice
reward please.”
“What for, my young lady?”
“You wished to see, and so I took the trouble to get up the show
for you.”
“I wished?”
“A Sensei of painting who had come up crossing the mountain,
took the trouble, I am told, to ask the old woman of a humble tea
house on the mountain pass to let him see me in my wedding
gown.”
This came so unexpectedly that I was out of a ready answer. Nor
did the woman give me any chance, she quickly came down on me:
 “All obliging, however sincere, can only be lost on a man so
forgetful,” came in mocking reproach, like a frontal blow. I was
beginning to get the worst of it, being at her mercy, unable to catch
up with the start she had of me.
“That bath tank show, last night, was then, also out of your
kindness?” I narrowly managed to regain my ground.
She made no reply.
“A thousand pardons for being so ungrateful. What would you
command of me in penance?” I went forward as far as I could in
anticipation; but in vain. She kept on looking up to the framed
calligraphy of the priest, Daitetsu, as if she saw and heard nothing.
Presently she read it in a soft murmur:
“Shadow of bamboo sweeping no dust rises.” Now she turned
right round to me and said as if she suddenly came back to herself:
“What did you say, Sensei?”
She said it with a studied loudness; but I was not to be caught.
“I met that priest a while ago.” I set myself in motion for her
benefit, imitating the “full round” movement of the earthquake
shaken pool of water.
“The Osho-san of Kaikanji? He is quite stout, isn’t he?”
“He asked me if I would paint in oil on his paper screen! Those
Zen priests are full of absurdities, arn’t they?”
“Probably that is why they get so fat.”
“I also met another, a young man.”
“Kyuichi, you mean.”
“Yes Kyuichi-san.”
“You seem to know so well.”
“No, I know Kyuichi-san only by name, but nothing else about
him. He seems to hate moving his lips.”
 “No, he is little shy, that is all. He is a mere boy.”
“A boy? Isn’t he of about the same age as you?”
“Ho, ho, ho, you think so? He is a cousin of mine. He is going to
the front, and came to say good-bye.”
“Is he stopping here?”
“No, he is staying with my brother.”
“I see. He came to take a cup of tea, then?”
“He likes ordinary hot water better than tea. But my father would
have him. Poor thing, he must have had a hard half hour of it. I
would have let him go before the party rose, if I were there.”
“Where have you been? The priest was asking after you—if you
were out again on one of your lonely walks?”
“Yes, I was. I made a round of Kagamiga Ike pond and
neighbourhood.”
“I should myself like to go and see that pond.”
“Do, by all means, Sensei.”
“Will it make a good picture?”
“It is a good place for drowning yourself.”
“I have no idea of ending my life in water for some time to come.”
“I may, before long.”
Too bold a joke for a woman, and I looked up into her eyes. She
seemed quite sound, more herself than I expected.
“Won’t you paint for me, Sensei, a picture of myself, drowned and
floating in water,—not struggling and in agony—but a nice little
picture of me floating in easy, painless eternal repose.”
“Eh?”
“Thunder and lightning, you are astonished?”
 Nami-san got to her feet lightly and three steps brought her to
the opening of my room. She turned back and threw at me the most
innocent of her smiles, as she walked out of it. For a long time I sat
immobile as one lost in reverie.
 CHAPTER X.
My curiosity brought me, the next day, to the Kagamiga Ike, a
pool of water, not more than half a mile in circumference, by an
actual survey, but looking immeasurably larger, when seen through
openings in the brushwood, embowering its zigzag water-edge. I left
it to my feet to take me where they liked, and I stopped when they
came to a halt at a spot close to and falling into water, determined
not to move till I got sick of it. Lucky that I could indulge in a whim
like this; for in Tokyo I would be run over by a tram car, if not sternly
chased away by a policeman. Ah! the city is a place where they
make a beggar of a peaceful citizen, and pay a high salary to
detectives who are all but boss pickpockets!
I sat on a damp cushion, which I found in incipient Spring grass,
satisfied that I was in the bosom of nature, where neither wealth nor
power could disturb me, and where I could heartily laugh at the folly
of Timon’s wrath. I then took out and lighted a cigarette, and as a
streak of smoke from the match took the shape of a dragon with its
tail tapering to a line, and vanished in a moment, I drew nearer to
the water edge. I looked into the clear and placid water of the pond
and saw some slender weeds reposing as in eternal peace in its not
necessarily unfathomable depth. Unlike the shear grass on the bank
which moved in the breeze, the weeds down in the bottom were
doomed, I fancied, never to stir till their surrounding water moved in
ripples, an event, which in all appearance, seemed never to come.
Possessed of willingness to be animate, but imprisoned in the watery
dungeon, they appeared to have been waiting in vain, morning after
morning, and evening after evening, for an opportunity to be
sported with, and eking out a life of forced immobility, unable to die.
I picked up a couple of pebbles and dropped one of them into the
water. I saw a couple or three of the thin stalks of weeds move
wearily, as some bubbles came up to the surface; but the next
moment more bubbles hid them from sight, as if they must not be
seen in motion. I threw in the other pebble, with some force this
time; but the poor resigned thing would not respond to my efforts to
awaken them, and I left the place and walked a little way up the
slow incline.
A huge tree stood over my new position of vantage, screening me
from the sun and making me feel chilly. Near the water’s edge, on
the other side of the pond, was an overhanging camellia tree in full
bloom. There is something very heavy and dull in the green of
camellia leaves, even when seen in the sunshine, and I would have
never known this particular plant but for its blood red flowers, which
are never attractive, though fiery and striking. I never look at
camellia flowers in a deep forest or mountain without wishing that I
had not seen them; their red is not a common red, but a red with
something weird in it like a she-demon in a fair woman’s mask, who
fascinates you with her black eyes and beauty and breathes poison
into your pores before you know it. The pear blossoms in rain never
fail to arouse a sentiment of pity; the aronia in pale moon light
awakens love; but the camellia’s cheerless red be-speaks a dark
poison and something ominous.
As I was looking at those dark red flowers, as if under a spell, one
of them fell into the water below, absolutely the only thing in motion
in the still Spring day. Presently another dropped. The eerie thing
about the camellia flower is that it never breaks up when it falls, as
do most other flowers, but keeps compactly together, never to let its
secret out, as it were. But one more fell, followed by another, after
an interval, by still another, and still another, like the minute gun.
Surely, I thought, the whole surface of the pond would turn red, by
and by. I fancied the water looked slightly reddish already where the
flowers were floating. Would they ever sink? Their red would melt,
they would rot, become mud and fill up the pool, until there would
be no more Kagamiga Ike, but a dry land after thousands of years.
Hoy! one more extra-big blood red flower fell, and drop, drop, drop,
followed by others, never ceasing to pass into eternity.
 I now became seized with a queer idea, how it would look to
paint a pond like this, with a beautiful woman floating in its water. I
went back to the spot where I first stopped and there continued to
think on the imaginary picture. Then with a tingling sensation,
rushed back to my memory, the joking remark of Nami-san of the
hot spring hotel, yesterday, that she should like to have me paint her
dead, but floating with a pleasant face in the water. Suppose, I
thought, I made her float in the water under that camellia. I
wondered if I could make my brush tell that the blood red flowers
were forever dropping, dropping, dropping into the water on her,
and she was forever lying in her watery bed, in her eternal peaceful
repose. But it was no easy matter, I told myself, to give expression
to the idea of super-human eternity, without rising above the level of
mortal humanity.
Besides, the greatest difficulty lay in the choice of the face. Nami-
san, with her usual expression of a discordant mixture of derision,
impetuosity and soft heart, would never do, I thought. The face
must bear no trace of mental or physical agony; but one with
effulgent light-heartedness would be worse. Perhaps I had better
borrow another woman’s face; but the racking of my head revealed
to me none to fit my imaginary picture, so that I felt that it must be
Nami-san, after all. Yet there was something lacking in her to suit
my purpose, and the tantalising part of it was how to make up for
that something, it being impossible to work my whilom fancy into it
to fill up what was lacking. How would it do to give the face a touch
of jealousy? But that would make it look too uneasy. How about
hatred, then? That would again be too strong. Anger? No, it would
spoil the whole effect. Resentment for some particular cause is
sometimes poetical and acceptable; but as an every day feeling, it is
too commonplace.
I thought and thought and thought, and it suddenly flashed upon
me that what was missing from Nami-san was pity and compassion.
Compassion is a feeling unknown to the gods, and yet is one that
makes man as near gods as possible. This was one sentiment which
I had never yet seen reflected in Nami-san, and I was convinced
that my picture would become an accomplished fact, the moment I
saw it aroused by some impulse or other and flashed across her
handsome face. For the moment, however, I had absolutely no idea
as to when or if ever, I should have the good fortune to see it in her.
A bantering sort of smile and a knitted brow bespeaking an eager
desire to get the better of you are the ever constant features of her
face and nothing can be done with them only. Hark! A rustling sound
as of somebody wading through dry leaves came, and the mental
plan of my picture, two-thirds of which I had finished forming went
to pieces. Looking up, I saw a man in tight sleeved kimono, loaded
with some faggots on his back, coming through the creeping
bamboo growths towards the Kaikanji, apparently from the
neighbouring hill.
“Fine weather, Sir,” said the man to me, taking off a towel from
his head. He made a bow, and as he did so, a flash from a
sharpened hatchet, stuck in his belt, caught my eyes. He was a
sturdily built men of about forty, with a face I remembered seeing
somewhere. He spoke to me familiarly:
“Danna paints, too?” I had my colour-box open by me.
“Yes, I have come out here, thinking I might make a picture of
this pond. This is a very lonely place; nobody comes round.”
“Yes, it is very much in the mountain.... Danna, you had a time of
it in rain, on that pass. I am sure, it was a bad toiling along you had
that time.”
“Eh? why, yes, you are the mago-san I saw, then?”
“Yes. I gather faggots as you see and take them down to the
town to sell.” Gembey took his load down from his back and sat on
it. His hand brought out a tobacco pouch, a very ancient affair, that
refused to tell whether it was of leather or of imitation leather. I
gave him a lighted match and said:
“It must be a great job for you to cross a place like that, every
day?”
 “No, Danna, I am used to it. Besides I don’t do it every day, but
only once in three days, and sometimes four days.”
“For myself, I should be excused even for once in four days.”
“Aha, ha, ha, ha. It is hard on my pony, and I generally make it
four days or so.”
“That is, you think more of your horse than yourself, eh? Ha, ha,
ha, ha!”
“Not quite that....”
“By the way, this pond looks very old. Have you any idea, how old
it is?”
“This has been here from olden times.”
“From olden times? How old?”
“Well, from a very long time ago.”
“From a very long time ago, I see.”
“A very long time ago, anyway, from the time when the Jo-sama
of Shiota threw herself into it.”
“Shiota? That spa-hotel you mean?”
“Yes.”
“You say the O-Jo-san drowned herself here? But she is alive,
very much alive there?”
“No, not that Jo-sama, but a Jo-sama of long, long ago.”
“Long, long ago? About when?”
“Well, a Jo-sama of very great long ago....”
“What made that Jo-sama of so long ago throw herself into
water?”
“That Jo-sama was, it is said, as beautiful as the present Jo-sama,
Danna-sama.”
 “Yes?”
“One day there came along a bonroji....”
“Bonroji? You mean that begging minstrel that used to come
round of old, playing his ‘shakuhachi’ pipe?”
“Yes, that ‘shakuhachi’ bonroji. While this bonroji was stopping at
Squire Shiota’s house, the beautiful Jo-sama took a fancy to him.
Would you call it fate or what? Anyhow, she said she must have him,
and cried.”
“Cried? You don’t say!”
“But the Squire would not have a bonroji for his son-in-law, and
drove away the party.”
“Drove away the bonroji?”
“Yes. The Jo-sama ran out of the house after him, and coming
here, she threw herself into the water from where that yonder pine
tree is standing. The whole place went into an awful excitement
then. It is said that the young Jo-sama had, at the time, a mirror
with her, and the pond has since come to be called Kagamiga Ike.
We still call this the Mirror Pond.”
“Oh, the pond has made a grave, already, at least for one
person?”
“A very scandalous affair, indeed.”
“This was about how many Squires back, do you know?”
“It is said to be a very long time back, and ... it is between you
and I, Danna-san.”
“What?”
“Every generation has had its mad one born in that Shiota family.”
“Oh?”
“A curse must be on that house. They are all saying that the
present Jo-sama is getting queer of late.”
 “Ha, ha, ha, ha. That seems improbable.”
“You don’t think so? But let me tell you that her mother had a
touch of it, too.”
“Is the old lady there?”
“No, she died last year.”
“Hum,” I said, looking at a thin cord of smoke rising from live
tobacco ashes, Gembey emptied on the ground, and then closed my
mouth. The man went away with the faggots on his back.
I had come out on my unhuman tour to do some painting. But
what with my thinking and musing, what with being made to listen
to old tales, I knew there would be no picture, no matter how many
days I might be at it. This very day I was at the pond with my
colour-box and tripod, and I thought I owed it to myself to make a
picture of the place, somehow or other. I sat on my tripod and
began to make a visual survey of the pool and its surroundings, to
make up my mind, on how much of the scenery I should take into
my picture. I knew my materials were pine trees, giant-leaved
creeping bamboos, rocks and a mirror-like pool of water.
The question was, how much of them should be covered in my
canvas. The creeping bamboos were growing quite close to the edge
of the water, and some of the rocks were ten feet high, while the
pine trees were scraping the sky and cast their shadows into the
water far and long, so much so that I could not see how I might
take them all on my canvas. I had half made up my mind that I
should paint only the reflections of the waters in the pond, feeling
almost certain that the novel idea would astonish the people. But
then the astonishment must be one arising from the sense of
admiration and appreciation for the substantial artistic value of the
production. How to solve this part of the problem occupied my
attention next. Naturally, my eyes directed themselves, to the
reflections in the pond.
Strangely enough no definite picture would come from the study
of shadows only, and it was irresistible that I should try to make
something by following the watery reflections back to their originals
on land. My eyes were closely studying the ten foot rock, from its
lowest point in the water to its body above, when I felt myself under
the spell of a fairy’s wand, just as they had travelled to the summit
of the cliff. I saw there a face in the struggling rays of setting sun
that stole through the leafy screen and were faintly falling on the
darkish top of the rock, the face of the woman, who had surprised
me as a midnight shadow, or a vision, who had surprised me in her
wedding gown, and had surprised me outside the bath-room! My
eyes refused to turn elsewhere, as if rooted to the centre of the pale
face of the woman who was standing fixedly on the rock, gently
straightening herself up to her full height. Oh! that instant! I jumped
on my feet. But the apparition had vanished, nimbly hopping down
the other side of the rock and as she did so, I thought I perceived
something red which resembled the camellia in her sash. The
declining sun, slanting closely over tree tops, was faintly dyeing the
trunks of the great pines, and below the creeping bamboos looked
greener than ever. I was once more taken by surprise.
 CHAPTER XI.
That night I gave myself up to renewing my acquaintance with
the priest, Daitetsu, by calling on him at Kaikanji temple, at the top
of the stone steps. The old priest received me, not effusively but
with a most cordial welcome.
“I am glad you have come. You must find life very tedious in
these parts?”
“The beautiful moon lured me out for a walk, and my feet brought
me here, to be plain, Osho-san.”
“Yes, the moon is beautiful to-night.”
The priest said this as he slid open the front shoji of his chamber.
The garden outside had nothing in it but two stepping stones and a
single pine tree; but beyond extended a stretch of sea, dimly visible
in the moonlight, with fishermen’s lights innumerably dotting the
watery surface as far as the horizon, where they seemed to change
into stars.
“What a beautiful view, Osho-san. Isn’t it a pity that you should
keep it shut out?”
“True; but don’t you see, it is not new to me, it being there before
me every night?”
“I should never be tired of looking over a view like this. I should
give up my sleep to be looking at it the whole night.”
“Ha, ha, ha, you are an artist and different from an old priest like
me.”
“But Osho-san, you are not the less an artist, as long as you see
the beautiful and enjoy it.”
 “That is so, though my artistic skill does not rise above drawing
an apology of Bodhidharma. Speaking of Bodhidharma, you see a
picture of the holy man in the niche there; it is from the brush of my
predecessor, here. Pretty good, isn’t it?”
True enough, there was a hanging picture of Bodhidharma which
had absolutely no claim to any artistic value, except that it was a
very innocent production, which gave no evidence of trying to hide
the artist’s want of skill.
“Why, it is artlessly good.”
“There need be no more about pictures that our kind make. We
are well satisfied as long as they represent our spirit.”
“They are far better than pictures that bespeak skill but breathe
base vulgarity.”
“Ha, ha, ha, you know how to praise things. By the by is there the
degree of Doctor for painters, these days?”
“No, Osho-san, there is no Doctor of Painting.”
“You see I am so far away from civilization and know nothing of
the latest novelties. I haven’t been in Tokyo not even once in the last
twenty years.”
“You have missed nothing, Osho-san. It is all noise and nothing
else in Tokyo.”
The priest treated me to a good cup of tea, and then went on to
ask:
“You seem to go about a great deal. Do you do so all for the
purpose of painting?”
“Well, I carry about with me my painting outfit; but I am not at all
particular about the actual painting itself.”
“So? Can it be, then, that you are travelling and sojourning for
the pleasure of doing so?”
 “Well, you might say so. But the fact is I can’t stand the life in
Tokyo. They begin to sniff about you, when you have lived there any
length of time.”
“That is strange. Can it be for sanitary purposes?”
“No, Osho-san, it is the detective that does it.”
“Detectives? The police then? The police stations and policemen,
must there be such things?”
“They are useless, at least, to artists.”
“Nor are they of any good to me. I have never had any occasion
to be taken care of by them.”
“I do not doubt you.”
“For that matter I don’t see why you should take their sniffing so
much to heart. If I were you I would let them do all the sniffing they
want. Even the police won’t bother you as long as you keep straight.
My predecessor used to tell me that a man must be able to make a
clean breast of everything within him in broad daylight at
Nihonbashi, the centre of Tokyo, and to find nothing to be ashamed
of in it. Till then, he cannot be said to have finished his culture. You,
my young friend, should strive to reach that stage of culture. Then
you shall have no need of fleeing from Tokyo.”
“You can rise to that height as soon as you shall have become a
true artist.”
“You had become one, then.”
“But the police sniffing is more than I can bear.”
“There, there, you are at it again. Look at that Nami-san of the
hot spring hotel. She was tormented by all kinds of worrying
thoughts on coming home to her father after being divorced from
her husband, until she at last came to me, asking me, to free her
from her mental anguish. I have been training her in the holy
teaching, and she is now mastering herself wonderfully. You have
seen yourself what a highly rational young woman she is.”
 “Yes, yes, I have thought she is a woman of no ordinary culture,
Osho-san.”
“Indeed, she is not. A few years ago I had under me a young
disciple named Taian. She saved him from walking off the narrow
path, and he is now on a fair way to attain high priesthood.”
 CHAPTER XII.
It was Oscar Wilde, if I remember right, who said that Jesus of
Nazareth was highly possessed of an artist’s gifts. I do not know
much about Christ; but I shall not hesitate to pronounce that the
priest, Daitetsu of Kaikanji, is full well-qualified for an appreciation of
this kind. Not that he takes much interest in art, nor that he is well
versed in such things. He is enviably content with a production
which can hardly be called a picture, and is innocent enough to think
that there should be the Doctor of Painting! Nevertheless, he is well-
qualified to be an artist. He is like a bag without a bottom:
everything passes through him freely. No impurities stagnate within
him. Only give him a touch of humour, and he shall be at home with
everything he comes across, everywhere he goes, and will thus
make a perfect artist.
As for myself, I shall never be a true artist as long as I cannot get
over my annoyance with being sniffed at by detectives. I may sit
before my easel and take up my palette, but that will not make me
an artist. I can assume myself to be a real artist only when I come
to a mountainous country-side like Nakoi and drink full of the joys of
Spring. Once in this state of emancipation, all the beauties of nature
become mine and I have made myself a first-class artist, even
though I may not paint the smallest picture. I may not equal
Michelangelo in art and take my hat off to Raphael in skill; but I
acknowledge no inferiority in me by the side of the great masters of
the past and present in the personality of an artist. I have not
painted a single picture since I came here. I may look to have
brought with me my colour-box, merely to satisfy a whim, and
people may laugh at me as an imitation. Let them laugh; I am none
the less a real artist, a sterling artist. It is not that one on this
psychological height necessarily produces great works; but I hold
that an artist who can turn out a worthy painting must have passed
through that stage.
Thus I thought as I drew at a cigarette after breakfast. The sun
had mounted high above the haze, and I saw the green of the trees
standing out in relief with uncommon clearness in the back mountain
when I opened the shoji.
The relations of air, and objects with colour are to me always the
most interesting study in this universe. Work out atmosphere by
giving first importance to colour, or let air be subordinate to the
object, or weave colour and objects into atmosphere, all kinds of
tune may be given to a picture, each depending upon a delicate
variation in treatment. It goes without saying that this tune shows
differently according to the particular tastes and fancies of individual
artists, just as it is natural that it is influenced by time and place.
There was never, for instance, a bright picture of scenery, painted by
an Englishman. It may be that they are not fond of bright pictures;
but even if they are, they cannot do anything with the atmosphere
they have in England. Goodall is an Englishman; but the tune of
colour is quite different in his productions. He never took any
scenery in his own country for his theme. He chose for his picture
the scenery of Egypt or Persia, where the atmosphere is much
clearer than in England. Those who see his paintings for the first
time wonder how an Englishman could bring out colours so clearly;
so brightly are they all finished.
As for individual taste, there can be no help for it. However, if it
be our object to paint Japanese scenery, we must work out a colour
and atmosphere peculiar to Japan. French paintings are good; but
you cannot call it a picture of Japanese scenery which is produced
by simply copying their colours. You must come in contact with
nature on the spot, studying, morning and evening, the shape and
colour of the clouds, the shade of haze, etc., being ever prepared to
go out with your tripod, the moment you see a colour which you
think just right. Colour in nature is to be seen but momentarily, and
once missed the same colour will not be easily caught again. The
mountain I was looking at was full of a colour which was a rare good
fortune for an artist to come across. I could not afford to miss it, and
I started to go into the mountain to make a copy of it.
I left my room through a side fusuma way and stepped out into
the verandah. The same moment my eyes caught the figure of
Nami-san, leaning against the verandah railing, a little distance from
me. Just as I began to call to her a word of greeting, she allowed
her left hand to drop. No sooner had this happened when I saw
something flash in her right hand and travel quickly two or three
times over her chest, and then disappear as suddenly with a clap.
The next instant she raised her left hand with a sheathed dagger in
it. The show was over and phantom vanished behind a shoji. I
wended my way to my sketching, thinking I had been given a
morning treat in a theatrical rehearsal.
I walked upward slowly and as I did so the thought of Nami-san
again possessed me. The first thing that occurred to me was that
she would make a fine star if she went on the stage. Most actors
and actresses assume visiting manners when before the foot-lights;
but with Nami-san, her home is her stage and she is always acting,
without knowing it. With her acting is natural. It may be that hers is
what may be called an æsthetic life. Indeed life would be
unbearable, with its constant surprises and alarms, if one did not
accept hers as theatrical acting. She would soon make you dislike
her, with her impulsive excesses, if you were to study her from the
ordinary viewpoint of the novelist, with the common-place
background of duty, humanity, etc.
Suppose entangling relations of some sort grew up between her
and myself; my mental agony would, I fancied, be then
indescribable. I had come out on my present sojourn, I told myself,
to be away from the “madding crowd,” and to make of myself a
confirmed artist. Everything that came to me through my two
windows must, therefore, be seen as a picture. I must not set my
eyes on any woman but that I saw in her a figure or character in a
“Noh” play, a drama, or poetry. Seen through this psychological
glass, I must say that of all the women I had ever met, Nami-san
was the one who acted most beautifully. Precisely because her
actions were all perfectly unintentional, with absolutely no idea of
showing off a beautiful performance, hers was always far more
fascinating than stage acting.
Such were my ideas, I must not be misunderstood, and it would
be the height of injustice to me to be censured as unfit to be a
member of society. A man is sometimes laughed at for acting
theatrically. This is all very well, when one derides the folly of
undergoing unnecessary self-sacrifices, in order merely to vindicate
one’s taste; but it is wholly unpardonable for curs, with no idea of
what tastes are, to scoff at others by judging things from their own
low level. Years ago a youth sought and met Death by leaping over a
five hundred foot waterfall. I have an idea that he gave his life that
must not be lost, all for the word “æsthetic beauty.” Death is heroic
in itself; but there is something mysterious in the motives that
prompt it. However, it is out of the question for anyone unable to
appreciate the heroism of death to laugh at the self-destruction of
Fujimura, the youth. Not gifted with the power of grasping the true
significance of the heroic ending of life, such a person is bound to
fail to resort to the heroic deed, even when circumstances make it
most proper, and I conclude, in this sense, that such a one has no
right to laugh at Fujimura’s tragic death. I am an artist given over
wholly to tastes and sentiments, and mingling with others in this
mundane world as I may, I am loftier than my vulgar and prosaic
neighbours. As a member of society I hold a position from which I
may well teach others. I can act more beautifully than those who
have no poetry, no painting, no artistic culture. In this man’s world a
beautiful act is right, just and upright, and he who translates justice,
righteousness and uprightness into his doings is a model citizen.
I had walked half a mile upward and came upon a tableland, with
trees weaving out the beautiful green of Spring on the North,
probably the same which I saw from my room in the Shiota hotel,
and which so fascinated me as to bring me out here with my
painting kit. I went about this way and that, beating the grass, in
search of a place of vantage. I awoke in no time to the fact that the
charming scenery I saw from the verandah was, after all, not so
easy to take on to a canvas, and besides the colour and atmosphere
were changing. The desire to paint slipped away from me, I knew
not where. With that ambition gone, it made no difference to me
where or how I sat. At random I lay me down on the young grass,
the roots of which the Spring sun was bathing with his warm rays,
and I thought I was crushing the unseen gossamer.
Presently I lay on my back, with wild dwarf quince blooming all
around me. Everything was so transporting that I felt I must write a
piece of poetry. I took out my sketch book and wrote down in it, line
after line, as they slowly came to me until I had eighteen of them to
round it up:

I left home full of thoughts within me.

Spring breezes played about my clothes as I came along.
Sweet is the young grass growing in the wheel tracks.
Neglected paths run into haze are faintly visible.
I plant my stick in the ground and look around.
Nature is in her robe of clear brightness.
Gentle yellow songsters are hopping to the tune of their
lovely melody.
Seeing plum blossoms falling like snow.
I walk across the wild field, which is far and wide.
Coming upon an old temple, I write a poem on its door.
With sorrowful eyes I look up to the cloud,
And see the wild geese homing across the sky.
My heart, why so softly quiet?
The past is far back, I forget good or bad.
At thirty I am getting old.
But Spring is lingering.
Strolling about I adapt myself to things around.
At other times I drink full of sweet fragrance.
 I read and reread the lines, pleased that they gave expression,
rather well, to my feelings as I lay among the vermilion flowers, in
sweet oblivion to the cares and worries of the world. Just then,
came “hem,” the sound of somebody clearing the throat, and it took
me by surprise, as I least expected any living soul in my fairyland. I
turned round and saw a man coming out of the wood screening the
brow of the mountain yonder. He was wearing a felt hat, which
shaded his eyes, that I imagined to be looking restlessly about. His
indifferent kimono and bare feet almost forced a conclusion that he
must be of the fraternity, the members of which are popularly known
as tramps. I thought, he might be going down the craggy path I had
come up; but no, he retraced his footsteps towards the wood. He did
not re-enter the wood, but returned towards the path. In short, he
was going backwards and forwards, as if in a walk; but his general
appearance told against the latter theory. He was shaking his head
now and again, and seemed to be thinking something, now halting,
now looking round. Possibly he was expecting somebody, it occurred
to me; how should I know?
I could not remove my eyes from the suspicious-looking man,
although he aroused no sense of fear or alarm in me. Nor was I
seized with any idea of making a picture of him. Nevertheless my
eyes were glued to him, in spite of myself. As I was following his
every movement, another figure came into the corner of my eye, as
the man came to a halt. The two seemed to recognise each other,
and my field of vision narrowed as they walked up toward each
other, until it became a single point. They stood face to face with a
verdant mountain rising on one side, and the out-stretching sea on
the other.
One of the pair was, of course, the tramp, and the other a
woman. It was Nami-san!
So soon as I recognised Nami-san, I remembered the dagger I
saw in her hand that morning. It was possible, even, probable, that
she had it with her now, as she stood before the ungainly man. The
thought chilled me, unhuman as I was.
 The two stood perfectly still, maintaining the same posture as
when they first faced each other. They might be talking but I could
not hear a word. Presently the man dropped his head forward and
Nami-san turned her face toward the mountain. A warbler was
singing in that direction, and she seemed to be listening, for all I
saw. A few moments later the man straightened himself up, now
carrying his head erect, and made a motion as if to walk away. The
same moment Nami-san changed her pose and turned her face
towards the sea. Something was just visible in the voluminous folds
of her obi, it might be the dagger. The man pulled himself up
proudly and started to go. Nami-san followed him two or three
steps. The man stopped. Did she, perchance, ask him to? In the
same moment he turned round, Nami-san thrust her hand into her
obi. Mercy! But it was not the dagger it took out, but a purse, the
dangling string of which swung gently to and fro in the breeze as the
fair hand held it out to the man. One foot planted firmly on the
ground and the other a little forward, the upper half of her body
slightly thrown backward, and the purple of the purse making a
strong contrast with the well shaped hand, the picture was truly
worth preserving. But the vision evaporated the moment the man
took the purse and disappeared into the wood.
Nami-san gave not a look back to the vanishing man; but she
turned right round and walked briskly toward where I lay buried in
the flowering quince. “Sensei! Sensei!” She called twice, as soon as
she came right in front of me. Wondering when she detected me, I
responded:
“What is it, O-Nami-san?”
I held up my head above the quince; my hat had dropped among
the grass.
“What can you be doing there, Sensei?”
“I was lying asleep, after a little poetising.”
“Now, now, no story-telling, Sensei. You must have seen the show
just now?”
 “Yes, I took the liberty to see just a little bit of it.”
“Ho, ho, ho. Not just a little bit of it, but you should have seen a
good deal of it.”
“To tell the truth, I saw a good deal of it.”
“There you are! Just come out of there, Sensei. Come out of the
quince, Sensei.”
I meekly obeyed the order.
“Have you got anything more to do in the quince bed?”
“No, nothing more. I was thinking of going home.”
“Well, then, we will go home together, Sensei.”
I again demonstrated my docility, by going back among the
quince, by picking up my hat, by gathering up my kits, and then
walking homeward with Nami-san.
“Have you painted anything, Sensei?”
“No, I gave it up.”
“You have not painted a single picture since you came to us?”
“No, but don’t you see, O-Nami-san, I fled from Tokyo, and
having come to a place like this, I must have everything ‘go as you
like’.”
“Speaking of ‘go as you like,’ Sensei, life would not be worth
living, unless you had it that way, wherever you happen to be. For
my part, I am so unconcerned about things that I do not feel
ashamed to have a scene like that seen by others.”
“No, I do not think you need be ashamed.”
“Perhaps, you are right, Sensei; but who do you think that man
was?”
“Well, I should imagine he is not a very rich man.”
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