Essentials Of Nursing Informatics 7th Edition

7th Edition Virginia Saba download

https://ebookbell.com/product/essentials-of-nursing-
informatics-7th-edition-7th-edition-virginia-saba-34116450

Explore and download more ebooks at ebookbell.com

Here are some recommended products that we believe you will be
interested in. You can click the link to download.

Essentials Of Nursing Informatics 6th Edition Mccormick Kathleen Saba

https://ebookbell.com/product/essentials-of-nursing-informatics-6th-
edition-mccormick-kathleen-saba-5673518

Essentials Of Nursing Informatics Study Guide Brixey Jack E Brixey

https://ebookbell.com/product/essentials-of-nursing-informatics-study-
guide-brixey-jack-e-brixey-5673522

Essentials Of Nursing Leadership Management 7th Edition Sally A Weiss

https://ebookbell.com/product/essentials-of-nursing-leadership-
management-7th-edition-sally-a-weiss-22276814

Essentials Of Nursing Research Appraising Evidence For Nursing

Practice Essentials Of Nursing Research Polit 7th Denise F Polit Phd
Faan

https://ebookbell.com/product/essentials-of-nursing-research-
appraising-evidence-for-nursing-practice-essentials-of-nursing-
research-polit-7th-denise-f-polit-phd-faan-2329800
Essentials Of Nursing Leadership Management Second Edition 2nd Edition
Patricia Kelly

https://ebookbell.com/product/essentials-of-nursing-leadership-
management-second-edition-2nd-edition-patricia-kelly-2485120

Essentials Of Nursing Leadership Management 6th Edition Sally A Weiss

Edd Rn

https://ebookbell.com/product/essentials-of-nursing-leadership-
management-6th-edition-sally-a-weiss-edd-rn-5137534

Essentials Of Nursing Research Appraising Evidence For Nursing

Practice Ninth Edition Beck

https://ebookbell.com/product/essentials-of-nursing-research-
appraising-evidence-for-nursing-practice-ninth-edition-beck-10020142

Essentials Of Nursing Leadership And Management 5th Edition 5th

Edition Diane K

https://ebookbell.com/product/essentials-of-nursing-leadership-and-
management-5th-edition-5th-edition-diane-k-1911096

Essentials Of Nursing Research Appraising Evidence For Nursing

Practice Eighth North American Edition Denise F Polit Phd Faan

https://ebookbell.com/product/essentials-of-nursing-research-
appraising-evidence-for-nursing-practice-eighth-north-american-
edition-denise-f-polit-phd-faan-4672680
 Essentials of
Nursing
Informatics

FM.indd 1 27-10-2020 14:03:57

 Notice
Medicine is an ever-changing science. As new research and clinical expe-
rience broaden our knowledge, changes in treatment and drug therapy
are required. The authors and the publisher of this work have checked
with sources believed to be reliable in their efforts to provide informa-
tion that is complete and generally in accord with the standards accepted
at the time of publication. However, in view of the possibility of human
error or changes in medical sciences, neither the authors nor the pub-
lisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein
is in every respect accurate or complete, and they disclaim all responsi-
bility for any errors or omissions or for the results obtained from use of
the information contained in this work. Readers are encouraged to con-
firm the information contained herein with other sources. For example
and in particular, readers are advised to check the product information
sheet included in the package of each drug they plan to administer to be
certain that the information contained in this work is accurate and that
changes have not been made in the recommended dose or in the con-
traindications for administration. This recommendation is of particular
importance in connection with new or infrequently used drugs.

FM.indd 2 27-10-2020 14:03:57

 Essentials of
Nursing
Informatics
SEVENTH EDITION

Virginia K. Saba, EdD, RN, FAAN, FACMI

CEO and President
SabaCare, Inc.
Arlington, Virginia
Distinguished Scholar, Emeritus
Georgetown University
Washington, District of Columbia
Professor, Adjunct
Uniformed Services University
Bethesda, Maryland

Kathleen A. McCormick, PhD, RN, FAAN, FACMI, FHIMSS

Principal/Owner
SciMind, LLC
North Potomac, Maryland

New York • Chicago • San Francisco • Athens • London • Madrid • Mexico City
Milan • New Delhi • Singapore • Sydney • Toronto

FM.indd 3 27-10-2020 14:03:58

Copyright © 2021 by McGraw Hill. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no
part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system,
without the prior written permission of the publisher.

ISBN: 978-1-26-045679-0
MHID: 1-26-045679-X

The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-045678-3,
MHID: 1-26-045678-1.

eBook conversion by codeMantra

Version 1.0

All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trade-
marked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringe-
ment of the trademark. Where such designations appear in this book, they have been printed with initial caps.

McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in
corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com.

TERMS OF USE

This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work
is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the
work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit,
distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You
may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to
use the work may be terminated if you fail to comply with these terms.

THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES
OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED
FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK
VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, IN-
CLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICU-
LAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work
will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its
licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any
damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through
the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special,
punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been
advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such
claim or cause arises in contract, tort or otherwise.
 CONTENTS

Contributors ix 9 Human–Computer Interaction • 153

Foreword xix Gregory L. Alexander
Preface xxi
10 Trustworthy Systems for Safe and Private
Acknowledgments xxiii
Healthcare • 163
Dixie B. Baker
Part 1 — Nursing Informatics
Technologies 1 11 Social Determinants of Health, Electronic
Health Records, and Health Outcomes • 181
Carol J. Bickford and Marisa L. Wilson
Marisa L. Wilson / Paula M. Procter
1 Historical Perspectives of Nursing
Informatics • 3 Part 3 — System Life Cycle 193
Virginia K. Saba / Bonnie L. Westra / Juliana J. Brixey Denise D. Tyler
2 Computer Systems Basics—Hardware • 29
12 System Design Life Cycle: A Framework • 195
Mary L. McHugh
Susan K. Newbold
3 Advanced Hardware and mHealth • 45
13 System and Functional Testing • 219
David J. Whitten / Kathleen G. Charters
Theresa (Tess) Settergren / Denise D. Tyler
4 Computer Systems Basics—Software • 57
14 System Life Cycle Tools • 235
Mary L. McHugh
Denise D. Tyler
5 Open Source and Free Software • 69
David J. Whitten Part 4 — Informatics Theory
6 Data and Data Processing • 101 Standards 251
Irene Joos / Cristina Robles Bahm / Ramona Nelson Virginia K. Saba
15 Healthcare Project Management • 253
Part 2 — System Standards 119 Barbara Van de Castle / Patricia C. Dykes
Virginia K. Saba and Joyce Sensmeier
16 The Practice Specialty of Nursing
7 Health Data Standards: Development, Informatics • 265
Harmonization, and Interoperability • 121 Carolyn Sipes / Carol J. Bickford
Joyce Sensmeier
17 Foundations of Nursing Informatics • 287
8 Standardized Nursing Terminologies • 137 Sarah Collins Rossetti / Susan C. Hull / Suzanne
Jane Englebright / Nicholas R. Hardiker / Tae Bakken
Youn Kim

FM.indd 5 27-10-2020 14:03:59

 vi C ontents

Part 5 — Policies and Quality Measures 28 Structuring Advanced Practice Knowledge:

in Healthcare 317 Curricular, Practice, and Internet
Kathleen Smith Resource Use • 455
Mary Ann Lavin
18 Establishing Nursing Informatics
in Public Policy • 319 29 Beyond EMR Implementation: Optimize and
Rebecca Freeman / Allison Viola
Enhance • 481
Ellen Pollack
19 Quality Measurement and the Importance
of Nursing Informatics • 329 30 Federal Healthcare Sector Nursing
Jean D. Moody-Williams
Informatics • 493
Stephanie J. Raps / Margaret S. Beaubien / Christine Boltz /
20 Using Six Sigma and Lean for Measuring Michael E. Ludwig / Chris E. Nichols / Gerald N. Taylor /
Quality • 341 Susy Postal
Evelyn J. S. Hovenga / Lois M. Hazelton / Sally R. Britnell
31 Monitoring Interoperability, Device Interface,
21 Informatics Applications to Support Rural and Security • 507
and Remote Health • 355 R. Renee Johnson-Smith / Jillanna C. Firth
Amy J. Barton
32 Population Health Informatics • 521
22 Communication Skills in Health IT, Karen A. Monsen
Building Strong Teams for Successful Health
IT Outcomes • 363 33 Informatics Solutions for Emergency Planning
Elizabeth (Liz) Johnson / Karen M. Marhefka
and Response • 535
Elizabeth (Betsy) Weiner / Lynn A. (Slepski) Nash
23 Nurse Scheduling and Credentialing
Systems • 381 34 Health Information Technology: Striving
Karlene M. Kerfoot / Kathleen Smith
to Improve Patient Safety • 553
Patricia P. Sengstack
24 Mastering Skills that Support Nursing
Practice • 393 35 Consumer Patient Engagement and
Melissa Barthold †
Connectivity in Patients with Chronic Disease
in the Community and at Home • 567
Hyeoun-Ae Park / Naoki Nakashima / Hu Yuandong /
Part 6 — Nursing Practice Applications 403 Yu-Chuan (Jack) Li
Heather Carter-Templeton
25 Translation of Evidence into Nursing Practice • 405 Part 7 — Advanced Applications for the
Heather Carter-Templeton Fourth Nursing IT Revolution 583
Kathleen A. McCormick
26 Improving Healthcare Quality and Patient
Outcomes Through the Integration of 36 New Models of Healthcare Delivery
Evidence-Based Practice and Informatics • 423 and Retailers Producing Big Data • 587
Lynda R. Hardy / Bernadette Mazurek Melnyk Susan C. Hull
27 Nursing Plan of Care Framework for HIT • 441 37 Artificial Intelligence in Healthcare • 605
Luann Whittenburg / Avaretta Davis Eileen Koski / Judy Murphy

Author deceased
†

FM.indd 6 27-10-2020 14:03:59

 Contents vii

38 Telehealth: Healthcare Evolution 45 The Evolution of the TIGER Initiative • 725

in the Technology Age • 615 Toria Shaw Morawski / Joyce Sensmeier
Teresa A. Rincon / Mark D. Sugrue
46 Initiation and Management of Accessible,
39 Nursing’s Role in Genomics and Information Effective Online Learning • 739
Technology for Precision Health • 635 Patricia E. Allen / Khadija Bakrim / Darlene Lacy
Kathleen A. McCormick / Kathleen A. Calzone
47 Social Media Tools in the Connected Age • 757
40 Big Data Analysis of Electronic Diane J. Skiba / Sarah Mattice / Chanmi Lee
Health Record (EHR) Data • 653
48 A Paradigm Shift in Simulation: Experiential
Roy L. Simpson
Learning in Virtual Worlds and Future Use
41 Nursing Data Science and Quality of Virtual Reality, Robotics, and Drones • 769
Clinical Outcomes • 663 E. LaVerne Manos / Nellie Modaress
Lynn M. Nagle / Margaret A. Kennedy / Peggy A. White

42 Nursing Informatics Innovations to Improve Part 9 — Research Applications 791

Quality Patient Care on Many Continents • 677 Veronica D. Feeg
Kaija Saranto / Ulla-Mari Kinnunen / Virpi Jylhä /
49 Computer Use in Nursing Research • 793
Pia Liljamo / Eija Kivekäs
Veronica D. Feeg / Theresa A. Rienzo / Marcia T. Caton /
43 Global eHealth and Informatics • 693 Olga S. Kagan
Hyeoun-Ae Park / Heimar F. Marin
50 Information Literacy and Computerized
Information Resources • 825
Part 8 — Educational Applications 707 Diane S. Pravikoff / June Levy
Diane J. Skiba
Appendix Clinical Care Classification (CCC) System:
44 Nursing Curriculum Reform and Healthcare Overview, Applications, and Analyses • 843
Information Technology • 709 Virginia K. Saba / Luann Whittenburg
Eun-Shim Nahm / Mary Etta Mills / Marisa L. Wilson
Index • 873

FM.indd 7 27-10-2020 14:03:59

 This page intentionally left blank

FM.indd 8 27-10-2020 14:03:59

 CONTRIBUTORS

Gregory L. Alexander, PhD, RN, FACMI, FAAN Cristina Robles Bahm, PhD, MSIS
Helen Young CUPHSONAA Professor Assistant Professor
Columbia University Program Coordinator
School of Nursing Chair Computer Science
New York, New York La Roche University
Chapter 9: Human–Computer Interaction Pittsburgh, Pennsylvania
Chapter 6: Data and Data Processing
Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN
Professor Emeritus, Texas Tech University–Health Melissa Barthold,† DNP, MSN, RN-BC, CPHIMSS,
Science Center FHIMSS
School of Nursing Principal
Lubbock, Texas Nursing Informatics Consulting
Chapter 46: Initiation and Management of Cape Coral, Florida
Accessible, Effective Online Learning Chapter 24: Mastering Skills that Support Nursing

Dixie B. Baker, PhD, MS, MS, BS, FHIMSS Amy J. Barton, PhD, RN, FAAN, ANEF
Senior Partner, Martin, Blanck and Associates Professor Daniel & Janet Mordecai Rural Health
Alexandria, Virginia Nursing Endowed Chair
Chapter 10: Trustworthy Systems for Safe College of Nursing
and Private Healthcare University of Colorado Anschutz Medical Campus
Aurora, Colorado
Suzanne Bakken, PhD, RN, FACMI, FIAHSI, Chapter 21: Informatics Applications to Support
FAAN Rural and Remote Health
The Alumni Professor of Nursing and Professor
of Biomedical Informatics Margaret S. Beaubien, MS, MSN, RN, CPHIMS
Columbia University Captain, NC, USN (Retired)
New York, New York Napa, California
Chapter 17: Foundations of Nursing Informatics Chapter 30: Federal Healthcare Sector Nursing
Informatics
Khadija Bakrim, EdD
Educational Technologist Carol J. Bickford, PhD, RN-BC, CPHIMS, FAMIA,
Texas Tech University Health Science Center FHIMSS, FAAN
School of Nursing Senior Policy Advisor
Lubbock, Texas American Nurses Association
Chapter 46: Initiation and Management of Accessible, Silver Spring, Maryland
Effective Online Learning Section Editor—Part 1: Nursing Informatics Technologies
Chapter 16: The Practice Specialty of Nursing Informatics
Author deceased
†

ix

FM.indd 9 27-10-2020 14:03:59

 x C ontributors

Christine Boltz, MA, MS, RN-BC, CPHIMS Marcia T. Caton, PhD, RN

Captain, NC, USN (Retired)/Online Instructor Professor
Excelsior College, School of Nursing Barbara H. Hagan School of Nursing and Health
Alexandria, Virginia Sciences
Chapter 30: Federal Healthcare Sector Nursing Malloy College
Informatics School of Nursing
Rockville Centre, New York
Sally R. Britnell, PhD, RN Chapter 49: Computer Use in Nursing Research
Lecturer
Auckland University of Technology Kathleen G. Charters, PhD, RN
Nursing Department Retired Nursing Informatics Consultant
School of Clinical Sciences Department of Defense
Auckland, New Zealand Sequim, Washington
Chapter 20: Using Six Sigma and Lean for Measuring Chapter 3: Advanced Hardware and mHealth
Quality
Avaretta Davis, DNP, MHS, RN
Juliana J. Brixey, PhD, MPH, RN Deputy Chief Nursing Informatics Officer
Associate Professor Veterans Affairs, Veterans Health Administration
University of Texas Health Science Center Washington, District of Columbia
at Houston Chapter 27: Nursing Plan of Care Framework for HIT
School of Biomedical Informatics
Cizik School of Nursing Patricia C. Dykes, PhD, RN, FACMI, FAAN
Houston, Texas Program Director Research, Center for Patient
Chapter 1: Historical Perspectives of Nursing Safety, Research, and Practice
Informatics Brigham and Women’s Hospital
Associate Professor of Medicine, Harvard Medical
Kathleen A. Calzone, PhD, RN, AGN-BC, School
FAAN Chair, American Medical Informatics Association
Research Geneticist (AMIA), Board of Directors
National Institutes of Health, National Cancer Boston, Massachusetts
Institute, Center for Cancer Research, Genetics Chapter15: Healthcare Project Management
Branch
Bethesda, Maryland Jane Englebright, PhD, RN, CENP, FAAN
Chapter 39: Nursing’s Role in Genomics and Senior Vice President & Chief Nurse Executive
Information Technology for Precision Health HCA Healthcare
Nashville, Tennessee
Heather Carter-Templeton, PhD, RN-BC, FAAN Chapter 8: Standardized Nursing Terminologies
The University of Alabama
Capstone College of Nursing Jillanna C. Firth, RN, BSN
Tuscaloosa, Alabama Roudebush VA Medical Center
Section Editor—Part 6: Nursing Practice Applications CIS/ARK/BCMA Coordinator
Chapter 25: Translation of Evidence into Nursing Indianapolis, Indiana
Practice Chapter 31: Monitoring Interoperability, Device
Interface, and Security

FM.indd 10 27-10-2020 14:03:59

 Contributors xi

Veronica D. Feeg, PhD, RN, FAAN Evelyn J. S. Hovenga, PhD, RN, FACHI, FACS,
Professor, Associate Dean FACN, FIAHSI
Barbara H. Hagan School of Nursing CEO, Professor & Director, eHealth Education PTY Ltd
Molloy College Director, Global eHealth Collaborative (GEHCO)
Rockville Centre, New York East Melbourne, Victoria
Section Editor—Part 9: Research Applications Australia
Chapter 49: Computer Use in Nursing Research Chapter 20: Using Six Sigma and Lean for Measuring
Quality
Rebecca Freeman, PhD, RN, FAAN, FNAP
University of Vermont Susan C. Hull, MSN, RN-BC, NEA, FAMIA
Vice President of Health Informatics Chief Health Information Officer
Burlington, Vermont CareLoop, Inc.
Chapter 18: Establishing Nursing Informatics Boulder, Colorado
in Public Policy Co-chair, Alliance for Nursing Informatics
Chapter 17: Foundations of Nursing Informatics
Nicholas R. Hardiker, PhD, RN, FACMI Chapter 36: New Models of Healthcare Delivery and
Professor of Nursing and Health Informatics and Retailers Producing Big Data
Associate Dean (Research & Enterprise)
School of Human and Health Sciences Elizabeth (Liz) Johnson, MS, FAAN, LCHIME,
University of Huddersfield FCHIME, CHCIO, FHIMSS, RN
Huddersfield, United Kingdom Retired Chief Innovation Officer
Chapter 8: Standardized Nursing Terminologies Tenet Health
Dallas, Texas
Lynda R. Hardy, PhD, RN, FAAN Chapter 22: Communication Skills in Health IT, Building
Director, Data Science & Discovery Strong Teams for Successful Health IT Outcomes
Associate Professor, Clinical
R. Renee Johnson-Smith, RN, MBA
The Ohio State University
Roudebush VA Medical Center
College of Nursing
Risk Manager
Columbus, Ohio
Indianapolis, Indiana
Chapter 26: Improving Healthcare Quality and Patient
Chapter 31: Monitoring Interoperability, Device
Outcomes Through the Integration of Evidence-Based
Interface, and Security
Practice and Informatics
Irene Joos, PhD, RN, MSIS
Lois M. Hazelton, RN, Dip App Sci (Nurs), B App Professor, IST
Sci (Ad Nurs), PhD (Entrepreneurship), FACN Adjunct Professor, Nursing
Independent Consultant and Researcher La Roche University
Nerrina, Victoria Pittsburgh, Pennsylvania
Australia Chapter 6: Data and Data Processing
Chapter 20: Using Six Sigma and Lean for Measuring
Quality

FM.indd 11 27-10-2020 14:03:59

 xii C ontributors

Virpi Jylhä, PhD, PT Ulla-Mari Kinnunen, PhD, RN

Senior Lecturer, Health and Human Services Adjunct Professor
Informatics Senior Lecturer, Health and Human Services
Department of Health and Social Management Informatics
University of Eastern Finland Department of Health and Social
Kuopio, Finland Management
Chapter 42: Nursing Informatics Innovations to University of Eastern Finland
Improve Quality Patient Care on Many Continents Kuopio, Finland
Chapter 42: Nursing Informatics Innovations
Olga S. Kagan, PhD, RN to Improve Quality Patient Care on Many
Adjunct Professor Continents
Barbara H. Hagan School of Nursing and Health
Sciences Eija Kivekäs, PhD, RN
Molloy College PostDoc Researcher, Health and Human Services
School of Nursing Informatics
Rockville Centre, New York Department of Health and Social Management
Chapter 49: Computer Use in Nursing Research University of Eastern Finland
Kuopio, Finland
Margaret A. Kennedy, PhD, MS, BScN, RN,
Chapter 42: Nursing Informatics Innovations
CPHIMS-CA, PMP
to Improve Quality Patient Care on Many
Chief Nursing Informatics Officer and
Continents
Managing Partner
Grevity Consulting Inc
Vancouver, British Columbia Eileen Koski, MPhil, FAMIA
Canada Program Director, Health Data & Insights, Center
Chapter 41: Nursing Data Science and Quality Clinical for Computational Health
Outcomes IBM T. J. Watson Research Center
Yorktown Heights, New York
Karlene M. Kerfoot, PhD, RN, FAAN Chapter 37: Artificial Intelligence in Healthcare
Chief Nursing Officer
API Healthcare/Symplr Darlene Lacy, PhD, RNC, CNE
Hartford, Wisconsin Associate Professor
Chapter 23: Nurse Scheduling and Credentialing Texas Tech University Health Sciences Center
Systems School of Nursing
Lubbock, Texas
Tae Youn Kim, PhD, RN Chapter 46: Initiation and Management of Accessible,
Associate Professor Effective Online Teaching
University of California Davis
Betty Irene Moore School of Nursing
Sacramento, California
Chapter 8: Standardized Nursing
Terminologies

FM.indd 12 27-10-2020 14:03:59

 Contributors xiii

Mary Ann Lavin, DSc, RN, ANP-BC (Retired), Michael E. Ludwig, MSN, RN-BC, CPHIMS
FNI, FAAN U.S. Army
Multidimensional Search and Design Consultant Chapter 30: Federal Healthcare Sector Nursing
Founder and President, TIIKO, LLC Informatics
Associate Professor Emerita
Saint Louis University E. LaVerne Manos, DNP, RN-BC, FAMIA
Trudy Busch Valentine School of Nursing Program Director
Saint Louis, Missouri Interprofessional Master of Science in Health
Chapter 28: Structuring Advanced Practice Knowledge: Informatics & Post-Master’s Certificate in Health
Curricular, Practice, and Internet Resource Use Informatics
Director, Informatics
Chanmi Lee, BSN, RN, FNP-C Director, Center for Health Informatics
Family Nurse Practitioner Clinical Associate Professor
Stride Community Health Center Kansas University Center for Health Informatics
Aurora, Colorado Kansas University School of Nursing
Chapter 47: Social Media Tools in the Connected Age Kansas City, Kansas
Chapter 48: A Paradigm Shift in Simulation:
June Levy, MLS Experiential Learning in Virtual Worlds and Future Use
Vice President of Virtual Reality, Robotics, and Drones
CINAHL Information Systems
Glendale, California Karen M. Marhefka, DHA, MHA, RHIA
Chapter 50: Information Literacy and Computerized Principal, Impacts Advisors
Information Resources Naperville, Illinois
Chapter 22: Communication Skills in Health IT,
Yu-Chuan (Jack) Li, MD, PhD, FACMI, FACHI, Building Strong Teams for Successful Health IT Outcomes
FIAHSI
Distinguished Professor and Dean, Graduate Heimar F. Marin, RN, MS, PhD, FACMI
Institute of Biomedical Informatics Alumni Professor, Nursing and Health
College of Medical Science and Technology Informatics
Taipei Medical University Federal University of São Paulo
Taipei, Taiwan Fellow, American College of Medical
Chapter 35: Consumer Patient Engagement and Informatics
Connectivity in Patients with Chronic Disease in the Editor-in-Chief, International Journal of
Community and at Home Medical Informatics
São Paulo, São Paulo
Pia Liljamo, PhD, RN Brazil
Development Manager Chapter 43: Global eHealth and Informatics
Oulu University Hospital Administrative Centre
Oulu, Finland Sarah Mattice, MS, RN
Chapter 42: Nursing Informatics Innovations Adjunct Instructor
to Improve Quality Patient Care on Many University of Colorado
Continents College of Nursing
Aurora, Colorado
Chapter 47: Social Media Tools in the Connected Age

FM.indd 13 27-10-2020 14:03:59

 xiv C ontributors

Kathleen A. McCormick, PhD, RN, FAAN, FACMI, Nellie Modaress, MS

FHIMSS Assistant to Online Learning
Principal/Owner Liaison to School of Nursing
SciMind, LLC University of Kansas Center for Health
North Potomac, Maryland Informatics
Book Editor and Section Editor—Part 7: Advanced Kansas City, Kansas
Applications for the Fourth Nursing IT Revolution Chapter 48: A Paradigm Shift in Simulation:
Chapter 39: Nursing’s Role in Genomics and Experiential Learning in Virtual Worlds and Future Use
Information Technology for Precision Health of Virtual Reality, Robotics, and Drones

Mary L. McHugh Karen A. Monsen, PhD, RN, FAMIA, FAAN

Retired Dean of Nursing Professor and Chair, Population Health and Systems
Los Angeles, California Cooperative
Chapter 2: Computer Systems Basics—Hardware University of Minnesota
Chapter 4: Computer Systems Basics—Software School of Nursing
Minneapolis, Minnesota
Bernadette Mazurek Melnyk, PhD, APRN-CNP,
Chapter 32: Population Health Informatics
FAANP, FNAP, FAAN
Vice President for Health Promotion
University Chief Wellness Officer Jean D. Moody-Williams, RN, MPP
Dean and Professor, College of Nursing Principal, Transitions, Trust and Triumph: Quality
Professor of Pediatrics & Psychiatry, College of Improvement and Patient Engagement
Medicine Fulton, Maryland
Executive Director, The Helene Fuld Health Trust Chapter 19: Quality Measurement and the Importance
National Institute for The Ohio State University of Nursing Informatics
Columbus, Ohio
Editor, Worldviews on Evidence-Based Nursing Toria Shaw Morawski, MSW
Chapter 26: Improving Healthcare Quality and Patient Sr. Manager, Professional Development
Outcomes Through the Integration of Evidence-Based Health Information Management Society System
Practice and Informatics (HIMSS)
Chicago, Illinois
Mary Etta Mills, ScD, RN, NEA, BC, FAAN Chapter 45: The Evolution of the TIGER Initiative
Professor
Organizational Systems and Adult Health Judy Murphy, RN, FACMI, LFHIMSS, FAAN
University of Maryland Chief Nursing Officer
School of Nursing IBM Global Healthcare
Baltimore, Maryland Minneapolis, Minnesota
Chapter 44: Nursing Curriculum Reform and Chapter 37: Artificial Intelligence in Healthcare
Healthcare Information Technology

FM.indd 14 27-10-2020 14:03:59

 Contributors xv

Lynn M. Nagle, PhD, RN, FAAN Susan K. Newbold, PhD, RN-BC, FHIMSS, FAMIA,
Director, Digital Health and Virtual Learning FAAN
Adjunct Professor Owner
Faculty of Nursing Nursing Informatics Boot Camp
University of New Brunswick Franklin, Tennessee
Adjunct Professor Chapter 12: System Design Life Cycle: A Framework
University of Toronto
Western University Chris E. Nichols, MHA, RN
Editor-in-Chief, Canadian Journal of Nursing Leadership LSSBB Program Manager
President Enterprise Intelligence & Data Solutions PMO
Nagle & Associates Inc. Defense Healthcare Management Systems PEO
Health Informatics Consulting Falls Church, Virginia
New Brunswick/Toronto, Canada Chapter 30: Federal Healthcare Sector
Chapter 41: Nursing Data Science and Quality Nursing Informatics
Clinical Outcomes Hyeoun-Ae Park, PhD, RN, FACMI, FAAN, FIAHSI
Eun-Shim Nahm, PhD, RN, FAAN Professor
Professor Seoul National University
Organizational Systems and Adult Health School of Nursing and Medical Informatics
University of Maryland Interdisciplinary Program
School of Nursing Seoul, Republic of Korea
Baltimore, Maryland Chapter 35: Consumer Patient Engagement and
Chapter 44: Nursing Curriculum Reform and Connectivity in Patients with Chronic Disease in the
Healthcare Information Technology Community and at Home
Chapter 43: Global eHealth and Informatics
Naoki Nakashima, MD, PhD
Professor/Director, Medical Information Center Ellen Pollack, MSN, RN-BC
Kyushu University Hospital, Japan Chief Nursing Informatics Officer
Fukuoka City, Japan UCLA Health
Chapter 35: Consumer Patient Engagement and Los Angeles, California
Connectivity in Patient with Chronic Disease in the Chapter 29: Beyond EMR Implementation: Optimize
Community and at Home and Enhance

Lynn A. (Slepski) Nash, PhD, RN, PHCNS-BC, FAAN Susy Postal, DNP, RN-BC
Captain (Retired), U.S. Public Health Service Chief Health Informatics Officer
Gaithersburg, Maryland Indian Health Service
Chapter 33: Informatics Solutions for Emergency Rockville, Maryland
Planning and Response Chapter 30: Federal Healthcare Sector Nursing
Informatics
Ramona Nelson, PhD, RN, BC, FAAN
Professor Emerita Diane S. Pravikoff, RN, PhD, FAAN
Slippery Rock University Vice President, Research (Retired)
President CINAHL Information Systems
Ramona Nelson Consulting Glendale, California
Pittsburgh, Pennsylvania Chapter 50: Information Literacy and Computerized
Chapter 6: Data and Data Processing Information Resources

FM.indd 15 27-10-2020 14:03:59

 xvi C ontributors

Paula M. Procter, RN, CertED (FE), MSc, SFHEA, Virginia K. Saba, EdD, RN, FACMI, FAAN, LL
FBCS, CITP, FIMIANI, IAHSI CEO & President
Professor of Nursing Informatics Sabacare.com
Department of Nursing and Midwifery Arlington, Virginia
Sheffield Hallam University Distinguished Scholar, Adjunct
Sheffield, United Kingdom Georgetown University
Chapter 11: Social Determinants of Health, Electronic Washington, District of Columbia
Health Records, and Health Outcomes Professor, Adjunct
Uniformed Services University
Stephanie J. Raps, MSN, RN-BC Bethesda, Maryland
Doctoral Candidate Book Editor and Section Editor—Part 1: Nursing
Daniel K. Inouye Graduate School of Nursing Informatics Technologies
Uniformed Services University of the Health Sciences Part 4: Informatics Theory Standards
Major, U.S. Air Force Chapter 1: Historical Perspectives of Nursing
Bethesda, Maryland Informatics
Chapter 30: Federal Healthcare Sector Nursing Appendix: Clinical Care Classification (CCC) System:
Informatics Overview, Applications, and Analyses

Kaija Saranto, PhD, RN, FACMI, FAAN, FIAHSI

Theresa A. Rienzo, BSN, RN, MS, MLIS, AHIP
Professor, Health and Human Services
Associate Librarian Health Sciences
Informatics
James E. Tobin Library
Department of Health and Social Management
Molloy College
University of Eastern Finland
Rockville Centre, New York
Kuopio, Finland
Chapter 49: Computer Use in Nursing Research
Chapter 42: Nursing Informatics Innovations to
Improve Quality Patient Care on Many Continents
Teresa A. Rincon, RN, PhD, CCRN-K, FCCM
Director of Clinical Ops & Innovation, Virtual Med Patricia P. Sengstack, DNP, RN-BC, FAAN
UMass Memorial Healthcare Associate Professor, Vanderbilt University School of
Assistant Professor, Graduate School of Nursing Nursing
University of Massachusetts Medical School Nursing Informatics Executive, Vanderbilt University
Worcester, Massachusetts Medical Center
Chapter 38: Telehealth: Healthcare Evolution in the Nashville, Tennessee
Technology Age Chapter 34: Health Information Technology: Striving
to Improve Patient Safety
Sarah Collins Rossetti, RN, PhD, FACMI, FAMIA
Assistant Professor of Biomedical Informatics and Joyce Sensmeier, MS, RN-BC, FHIMSS, FAAN
Nursing Senior Advisor, Informatics
Columbia University Medical Center Health Information Management Society System
New York, New York (HIMSS)
Chapter 17: Foundations of Nursing Informatics Chicago, Illinois
Section Editor—Part 2: System Standards
Chapter 7: Health Data Standards: Development,
Harmonization, and Interoperability

FM.indd 16 27-10-2020 14:04:00

 Contributors xvii

Theresa (Tess) Settergren, MHA, MA, RN-BC Mark D. Sugrue, RN-BC, MSN, FHIMSS
Director, Nursing Informatics (Retired) Managing Director, Clinical Delivery & Informatics
University of Minnesota Solutions
Minneapolis, Minnesota Commonwealth Medicine
Chapter 13: System and Functional Testing University of Massachusetts Medical School
Member, HIMSS North America Board of Directors
Roy L. Simpson, DNP, RN, DPNAP, FAAN, FACMI (2019–2020)
Assistant Dean, Technology Management and Chair, HIMSS North America Board of Directors
Clinical Professor (6/2020–2021)
Doctoral Program: Doctorate Nursing Shrewsbury, Massachusetts
Practice Chapter 38: Telehealth: Healthcare Evolution in the
Nell Hodgson Woodruff School of Nursing Technology Age
Emory University
Atlanta, Georgia Gerald N. Taylor, MD, MPH
Chapter 40: Big Data Analysis of Electronic Health Flight Surgeon, Diplomate American Board of
Record (EHR) Data Preventive Medicine
Captain, USPHS
Diane J. Skiba, PhD, FACMI
Coast Guard Chief Medical Informatics Officer
Professor Emeritus
Washington, District of Columbia
University of Colorado
Chapter 30: Federal Healthcare Sector
Aurora, Colorado
Nursing Informatics
Media Editor
Chapter 47: Social Media Tools in the Connected Age
Denise D. Tyler, DNP, MSN/MBA, RN-BC
Carolyn Sipes, PhD, CNS, APRN, PMP, RN-BC, Clinical Specialist
NEA-BC, FAAN Visalia, California
Professor, Core Faculty, PhD Program Section Editor—Part 3: System Life Cycle
Walden University Chapter 13: System and Functional Testing
Minneapolis, Minnesota Chapter 14: System Life Cycle Tools
Chapter 16: The Practice Specialty of Nursing
Informatics Barbara Van de Castle, DNP, APRN-CNS, OCN,
RN-BC
Kathleen Smith, MScEd, RN-BC, FHIMSS
Assistant Professor
Managing Partner
University of Maryland School of Nursing
Informatics Consulting and Continuing
Baltimore, Maryland
Education, LLC
Nurse Educator
Weeki Wachee, Florida
Sidney Kimmel Comprehensive Cancer Center
Section Editor—Part 5: Policies and Quality
Johns Hopkins University
Measurement in Health Care
Baltimore, Maryland
Chapter 23: Nurse Scheduling and Credentialing
Chapter 15: Healthcare Project Management
Systems

FM.indd 17 27-10-2020 14:04:00

 xviii C ontributors

Allison Viola, MBA, RHIA Luann Whittenburg, PhD, RN-BC, FNP-BC,

Director, Guidehouse CPHIMS, FHIMSS, FAAN
Washington, District of Columbia Consultant, Health Informatics
Chapter 18: Establishing Nursing Informatics Fairfax, Virginia
Chapter 27: Nursing Plan of Care Framework for HIT
Elizabeth (Betsy) Weiner, PhD, RN-BC, FACMI, Appendix: Clinical Care Classification (CCC) System:
FAAN Overview, Applications, and Analyses
Senior Associate Dean for Informatics
Centennial Independence Foundation Professor of Marisa L. Wilson, DNSc, MHSc, RN-BC, CPHIMS,
Nursing FAMIA, FAAN
Vanderbilt University School of Nursing Associate Professor
Nashville, Tennessee Interim Department Chair: Family, Community and
Chapter 33: Informatics Solutions for Emergency Health Systems
Planning and Response Health Systems Leadership Pathway Director
The University of Alabama at Birmingham
Bonnie L. Westra, PhD, RN, FAAN, FACMI School of Nursing
Associate Professor Emerita Birmingham, Alabama
University of Minnesota Section Editor—Part 1: Nursing Informatics
School of Nursing Technologies
Minneapolis, Minnesota Chapter 11: Social Determinants of Health, Electronic
Chapter 1: Historical Perspectives of Nursing Health Records, and Health Outcomes
Chapter 44: Nursing Curriculum Reform and
Peggy A. White, RN, BA, MN Healthcare Information Technology
Consultant, Canadian Nurses Association—
Canadian Health Outcomes for Better Information Hu Yuandong, MD
and Care Initiative Deputy Chief
Co-Lead, National Nursing Data Standards Initiative Physician Institute of Chronic Disease
Thornbury, Ontario Guizhou Provincial Center for Disease Control
Canada Guizhou, China
Chapter 41: Nursing Data Science and Quality Clinical Chapter 35: Consumer Patient Engagement and
Outcomes Connectivity in Patients with Chronic Disease in the
Community and at Home
David J. Whitten, MSC
Medical Informatics
Central Regional Hospital
Department of Health and Human Services (DHHS)
Butner, North Carolina
Chapter 3: Advanced Hardware and mHealth
Chapter 5: Open Source and Free Software

FM.indd 18 27-10-2020 14:04:00

 FOREWORD

In the years since the previous edition of Essentials in ultimately, build wisdom—into nursing practice, nursing
Nursing Informatics was published, U.S. hospitals have informatics is uniquely positioned to help lead the opti-
achieved nearly universal adoption of electronic health mization journey that will simplify data capture, promote
record (EHR) systems. Physician offices are only slightly sharing of data in a mobile environment, and create high-
behind in joining the digital ranks, and health profession- performing, patient-centric clinical information systems.
als across the nation now utilize EHR systems in daily The vision for a better future of healthcare is tightly
practice. The “HITECH Act” has forever changed health associated with the future of health information technol-
informatics, and we now face new challenges in improv- ogy, and data are the fuel for this journey. Thus, nurse
ing usability, interoperability, and learning capability of informaticists are critical healthcare leaders for the 21st
these systems. With the rise of artificial intelligence and century, experts in the right place at the right time, bring-
a need to reduce documentation burden required by cur- ing the clinical, technical, and leadership skills together to
rent EHR systems, we see significant opportunity and create effective partnerships among their numerous con-
responsibility for healthcare providers to address these stituencies—leadership teams, clinicians, data scientists,
challenges. Nurse informaticists are at the center of this information technologists, and more. Their role is central
transformational opportunity. in advancing value and science-driven healthcare, and so
Historically, care teams communicated primarily their work in moving healthcare informatics from data
through written notes in the patient chart. Paper repre- management to decision support is essential.
sented a technical barrier, as the best patient care is depen- In the 15 years since the call for EHRs was made in
dent on data availability over time, across locations, and the 2004 Presidential State of the Union message, we have
among healthcare team members—including the patient. witnessed rapid evolution of health information technol-
Access to the most accurate and complete information ogy and its use in healthcare systems. The next 15 years
remains vital, and nursing informaticists are leading much will bring the increasing convergence of data from myr-
of the work being done to improve the speed, accuracy, iad sources outside of the formal healthcare setting into
and utility of clinical information. the context of clinical care. We will move up the analytic
We have made progress in gaining nearly instant access hierarchy from descriptive to diagnostic, predictive, and
to patient data and evidence-based decision support that ultimately prescriptive and autonomous systems. Thus,
enables nurses, physicians, and other clinicians to make the future of this field promises both challenge and oppor-
better decisions about patient care. These technologies, tunity for prepared participants.
however, require continued optimization of the tech- Just as the field has evolved, so has nursing informat-
nology, the interoperability, and the workflow to drive ics. Its practitioners have already provided tremendous
improvement in user experience, reduce documentation energy, insight, and leadership in helping to establish the
burden, and improve patient outcomes. necessary infrastructure and in driving gains in healthcare
The accelerating demands for gathering and using technology competency, information literacy, and better
data to improve patient care and clinical operations have healthcare outcomes. Now more than ever, we believe
increased awareness of informatics as a core skill, inten- nursing informatics holds great promise to enhance the
sifying the need for clinicians to better understand these quality, continuity, value, and experience of healthcare.
increasingly ubiquitous technologies. This edition incor-
Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI
porates updated teaching aids to help educators develop
President, Clinical Services Group and Chief Medical
more sophisticated users of technology, who are equipped
Officer
to improve processes and workflows that result in safer,
HCA Healthcare
more effective, and efficient patient care.
As the specialty that integrates nursing science, com- Jane D. Englebright, PhD, RN, CENP, FAAN
puter science, and information science to manage and Senior Vice President and Chief Nurse Executive
communicate data, information, and knowledge—and HCA Healthcare

xix

FM.indd 19 27-10-2020 14:04:00

 This page intentionally left blank

FM.indd 20 27-10-2020 14:04:00

 PREFACE

This seventh edition of Essentials of Nursing Informatics (Chap. 36), Artificial Intelligence in Healthcare (Chap. 37),
was initiated in response to requests by educators to pro- Telehealth: Healthcare Evolution in the Technology Age
vide a digital as well as an online version for faculty to use (Chap. 38), Nursing’s Role in Genomics and Information
in the development of their course work and by nurses Technology for Precision Health (Chap. 39), Big Data
and other users of the sixth edition. We expanded the Analysis of Electronic Health Record (EHR) Data (Chap.
content to stay current, since the publisher does not plan 40), Nursing Data Science and Quality Clinical Outcomes
to generate a Study Guide for this version. To do so, we (Chap. 41), Nursing Informatics Innovations to Improve
have added Questions and Answers in each chapter as Quality Patient Care on Many Continents (Chap. 42), and
well as added a Summary in each of the nine parts and Global eHealth and Informatics (Chap. 43). We requested
one Appendix of the text. Further with the updated ANA authors to include updates on the digital health require-
Certification Examination, we returned the basic, detailed ments, policies, and regulations as a result of the COVID-19
Fundamental Chapters to update so that the chapters pandemic.
completely address their focus and scope. The updates in chapters include new references, poli-
Each of the nine parts of this edition has had a Section cies, and skills required by nurses in the field. A complete
Editor to assist the authors with their content: Part 1: update and an overview of the Federal Health Care Sector
Nursing Informatics Technologies—Carol J. Bickford Nursing Informatics are described by experts represent-
and Marisa L. Wilson; Part 2: System Standards— ing all the federal sectors. The Veteran’s Administration
Virginia K. Saba and Joyce Sensmeier; Part 3: System Nursing Plan of Care Framework is described. Instead
Life Cycle—Denise D. Tyler; Part 4: Informatics Theory of an International Section, the nurse authors from
Standards—Virginia K. Saba; Part 5: Policies and Quality Australia, South Korea, Finland, South America, Canada,
Measures in Healthcare—Kathleen Smith; Part 6: Nursing the United Kingdom, and North America have described
Practice Applications—Heather Carter-Templeton; Part their expertise in Six Sigma, Measuring and Evaluating
7: Advanced Applications for the Fourth Nursing IT Quality, describing Consumer Patient Engagement and
Revolution—Kathleen A. McCormick; Part 8: Educational Connectivity in Patients with Chronic Diseases in the
Applications—Diane J. Skiba; and Part 9: Research Community and in their Home, and Global eHealth ini-
Applications—Veronica D. Feeg. For this edition, faculty tiatives in Nursing Informatics. Their chapters represent
recommended that we write a part summary introducing the expertise that they bring to Essentials of Nursing
important concepts in each part. Informatics, seventh edition.
This book was written by experts in nursing and infor- Our new Media Editor, Diane J. Skiba, is considering
matics, but when we were editing this book, the most including a website for slides, abstracts, and any other
unusual circumstances occurred. The COVID-19 pan- materials of interest that the authors determined would
demic swept across continents. Nurses in practice were support the faculty and/or enhance the educational pro-
stretched by large volumes of critical care to a large cohort cess. We feel that this new edition will provide the new
of patients. Unique digital concepts were developed on theories, federal policies, and new content that have
site, implemented to large groups of healthcare profes- impacted the field of Nursing Informatics that are con-
sionals in the ICU, the hospital, nearby local pop-up hospi- tinually changing.
tals, primary care offices, networks of specialty healthcare Virginia and Kathleen have felt that they have, dur-
workers, and skilled nursing facilities and nursing homes. ing the past 20+ years, and their six editions, with their
The mandate for interconnected healthcare, telehealth, specialist authors in the field, provided the most current
and digital education quickly became an adopted norm. and reliable information as this new Nursing Specialty
Several new chapters were added in Part 7: Advanced advanced, grew, and changed with the technological
Applications for the Fourth Nursing IT Revolution advancements that impacted on the changing healthcare
(Kathleen McCormick—Section Editor). This part has the processes. We feel honored that this text has been used by
following chapters: New Models of Healthcare Delivery the key administrative leaders, educators, and researchers

xxi

FM.indd 21 27-10-2020 14:04:00

 xxii P reface

in the field. We feel that this text has helped keep Nursing teach the content, assist nurses with the certification
Informatics in the forefront of our discipline. We hope you requirements, and help us advance Nursing Informatics in
will be as pleased with this seventh edition as you have the 21st century.
been with the past editions. We hope it will help faculty
Dr. Virginia K. Saba
Dr. Kathleen A. McCormick

FM.indd 22 27-10-2020 14:04:00

 ACKNOWLEDGMENTS

This seventh edition of Essentials of Nursing Informatics is We also want to especially remember those authors and
dedicated to all the section editors, chapter authors, and other supporters of Nursing Informatics who have left us
their co-authors. Each of these prestigious contributors last year: Helen Connors, Kathleen (Milholland) Hunter,
are experts in their respective positions, implementing Margaret Ross Kraft, Melissa Barthold, Julie McAfoos,
systems, policies, research, and educational programs to Andrew McLaughlin, Dr. Donald, Lindberg, and others
support and advance Nursing Informatics in this country who have left their mark on the field.
and abroad. The authors also acknowledge their families because
We acknowledge our international colleagues in without their encouragement and help this book would
Nursing Informatics. We also acknowledge the McGraw not be a reality. We thank the Lord for giving us the oppor-
Hill staff Susan Barnes Oldenburg, Richard Ruzycka, and tunity to embark on a seventh edition and for the help we
Christina Thomas and their contractors Touseen Qadri received in completing it.
from MPS Limited who contributed to the editing of this
book, completing the production of this book, as well as
supporting the expansion of the book with new resources. Dr. Virginia K. Saba
Dr. Kathleen A. McCormick

xxiii

FM.indd 23 27-10-2020 14:04:00

 This page intentionally left blank

FM.indd 24 27-10-2020 14:04:00

 part 1
Nursing Informatics
Technologies
Carol J. Bickford and Marisa L. Wilson

A new feature of the seventh edition of Essentials in Nursing Informatics is a part summary that provides an overview
for each of the nine parts of this edition. Each part represents a specific focus on this Nursing Informatics specialty and
provides appropriate information in separate chapters. The coronavirus pandemic that occurred during the publishing
process also allowed some authors to address its impact on specific practice areas.
The informatics nurse uses data to create information and knowledge to support best care practices. The informatics
nurse engages the data to information to knowledge process using technology to support patient care, increase effi-
ciency, ensure quality, and improve outcomes. In order to do this, the informatics nurse needs to understand the founda-
tions of computer hardware and software as well as the processes for managing data and information. Understanding
how computer hardware and software works is core to fulfilling the tenets of nursing informatics as outlined in the
American Nurses Association (ANA) Nursing Informatics: Scope and Standards of Practice, Second Edition. Part 1 content
description follows.
Chapter 1, entitled Historical Perspectives in Nursing Informatics, authored by Dr. Virginia K. Saba, Dr. Bonnie L. Westra,
and Dr. Julie J. Brixey, provides a historical overview of Nursing Informatics (NI) during 10-year period starting in the 1960s
with the introduction of computer technology in healthcare. The chapter provides landmark events that influenced the
growth of NI as a new nursing specialty. It provides an update on new activities since the previous edition, including
new information on where and who were involved in advancing this specialty. It includes the new criteria, established
by the NI pioneers, that addressed nursing practice standards, educational content, certification requirements, etc. It also
updated the Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics table with the name of
the major NI pioneer involved.
Chapter 2, Computer Systems Basics—Hardware, authored by Dr. Mary L. McHugh, provides a helpful overview of basic
computer hardware components, their characteristics, and functions. Because computers are ubiquitous in everyone’s
personal life and the healthcare industry, an understanding of the operations of such an infrastructure is foundational for
the informatics nurse. The five basic types of computers and the associated internal components and diverse peripherals
are described, as is the critical connectivity provided by network hardware.

ch01.indd 1 22-10-2020 03:11:52

 Chapter 3, developed by Dr. David J. Whitten who updated Dr. Kathleen Charters’ earlier description of Advanced
Hardware and mHealth supports innovative mobile healthcare models. This chapter informs the readers of the use of
increasingly sophisticated mechanical devices and electronic systems that will allow providers to provide care, con-
sultation, and communications in and across a multitude of settings. This chapter reviews the use of advanced tablets,
smartphones, wearables, and implantable or injectable devices made possible by the acceleration of increasingly sophis-
ticated and powerful hardware within an infrastructure that supports these activities.
Chapter 4, Computer Systems Basics—Software, authored by Dr. Mary L. McHugh, clarifies the differences and com-
plementary interrelationships of the three basic types of software: system software, utility programs, and applications
software. Discussion of the evolution of the generations and levels of programming languages promotes appreciation
of the complexity of today’s information systems’ environments and the value of expert programmers, colleagues, and
specialists partnering with the informatics nurse to ensure continuity of operations and services.
In Chapter 5, Drs. David J. Whitten expanded the previous authors’—Drs. Peter Murray and W. Scott Erdley—focus on
an important topic Open Source and Free Software or Free/Libre Open Source Software (FLOSS). Most informatics nurses
will work with vendor software products. However, they need to be aware of the resources available for use that are free
and open source. The informatics nurse needs to be familiar with the risks and rewards of using this software and the
differences between this and proprietary software when making choices. The authors provide a history of FLOSS, along
with development models, that dates back to the 1950s. They describe the benefits and issues related to the choice
to use FLOSS versus proprietary software. Whitten also provided detailed steps that one would consider when choos-
ing software, whether FLOSS or proprietary. The authors also cover the topic of licensing, which with the FLOSS model
encourages sharing of the software to facilitate dissemination.
Chapter 6 covers Data and Data Processing. Drs. Irene Joos, Cristina Bahm, and Ramona Nelson offer a broad presenta-
tion of this topic. Nelson’s Data to Information to Knowledge to Wisdom Model’s megastructures and concepts underline
NI, as well as processes for creating and using knowledge that the data care providers collect. In this chapter, the authors
describe important concepts in generating data. They introduce information on big data, data repositories, database
management systems, database models, and processes for curating data. The function and processes of interoperability
are described. Auditing data, information creation, and interpretation in the form of analytics are explained. Clinical
decision support and expert systems are presented as examples of processes using data to support value-based care.

ch01.indd 2 22-10-2020 03:11:52

 1
Historical Perspectives
of Nursing Informatics
Virginia K. Saba / Bonnie L. Westra / Juliana J. Brixey

• OBJECTIVES
1. Identify a brief historical perspective of nursing informatics.
2. Explore lessons learned from the pioneers in nursing informatics.
3. List the major landmark events and milestones of nursing informatics.

• KEY WORDS
Computers
Computer Literacy
Computer Systems
Data Standards
Electronic Health Records (EHR)
Healthcare Information Technology (HIT)
Information Systems
Internet
Nursing Informatics (NI)

referring to technology that captures, processes, and gen-

OVERVIEW erates healthcare information. Computerization and/or
Nursing Informatics is a phrase that evolved from the electronic processing affect all aspects of healthcare deliv-
French word “informatique” which referred to the field ery including (a) provision and documentation of patient
of applied computer science concerned with the pro- care, (b) education of healthcare providers, (c) scientific
cessing of information such as nursing information. The research for advancing healthcare delivery, (d) administra-
computer was seen as a tool that could be used in many tion of healthcare delivery services, (e) reimbursement for
environments. patient care, (f ) legal and ethical implications, as well as
In the early 1960s, the computer was introduced into (g) safety and quality issues.
healthcare facilities for the processing of basic adminis- Since the inception of the computer, there has been
trative tasks. Thus the computer revolution in healthcare a shift from the use of mainframe, mini, or microcom-
began and led to today’s healthcare information technol- puters (PCs) to integrating multiple technologies and
ogy (HIT) and/or electronic health record (EHR) systems. telecommunication devices such as wireless, handheld,
The importance of the computer as an essential tool mobile computers, and smart (cell) phones designed to
in HIT systems and the delivery of contemporary health- support the continuity of care across healthcare settings
care is indisputable. HIT is an all-encompassing term and HIT systems. There has also been a shift from storage

ch01.indd 3 22-10-2020 03:11:52

 4 P art 1 • N ursing I nformatics T echnologies

devices to cloud storage. Furthermore, there is less need demonstrate nursing’s commitment to Computers and
to develop written instructions for software programs Nursing including Information Technology.
as today’s applications are icon-based, user-friendly, and
menu-driven. Additionally, video tutorials are available for Prior to 1960s Computers were first developed in the
many programs. Touch-screen devices are replacing the late 1930s to early 1940s. As computers have evolved,
need for a mouse. computing power has increased. This was attributed to
Today, computers in nursing are used to manage the increasing number of transistors or chips placed in
patient care information, monitor quality, and evaluate an integrated circuit. In the mid-1960s Gordon Moore
outcomes. Computers and networks are also being used noted that the number doubled approximately every two
for communicating (sending and receiving) data and mes- years. This argument has become known as Moore’s law
sages via the Internet, accessing resources, and interacting (Techopedia, 2019).
with patients on the Web. Nurses are increasingly using Use of computers in the healthcare industry did not
systems for planning, budgeting, and policy-making for occur until the 1950s and 1960s. During this time, there
patient care services. Computers are also used to docu- were only a few experts nationally and internationally
ment and process real-time plans of care, support nursing who formed a cadre of pioneers that adapted computers
research, test new systems, design new knowledge data- to healthcare and nursing which was undergoing major
bases, develop data warehouses, and advance the role of changes. Several professional advances provided the impe-
nursing in the healthcare industry and nursing science. tus for the profession to embrace computers—a new tech-
Moreover, computers are enhancing nursing education nological tool. Computers were initially used in healthcare
and distance learning with new media modalities. facilities for basic office, administrative, and financial
This chapter is an updated and revised version of the accounting functions. These early computers used punch
chapter “Historical Perspectives of Nursing Informatics” cards to store data and card readers to read computer pro-
(Saba & Westra, 2015) published in the 6th edition of the grams, sort, and prepare data for processing. Computers
Essentials of Nursing Informatics (Saba & McCormick, were linked together and operated by paper tape using
2015). In this chapter the significant events influencing teletypewriters to print their output. As computer technol-
the growth of nursing informatics (NI) as a nursing spe- ogy advanced, healthcare technologies also advanced. The
cialty are analyzed according to (1) seven time periods, major advances are listed chronologically in Table 1-1.
(2) a view of the newest technological innovations used by
nurses, (3) a description of Nursing Informatics Pioneers 1960s During the 1960s the uses of computer technology
including a synthesis of lessons learned from videotaped in healthcare settings began to be explored. Questions such
interviews with NI pioneers, (4) electronic health records as “Why use computers?” and “What should be comput-
from a historical perspective, and (5) landmark events in erized?” were discussed. Nursing practice standards were
nursing and computers, with Table 1-1 listing those events reviewed, and nursing resources were analyzed. Studies
that influenced the introduction of computers into the were conducted to determine how computer technology
nursing profession including key “computer/informatics” could be utilized effectively in the healthcare industry and
nurse that directed the activity. Also, Table 1-2 lists cur- what areas of nursing should be automated. The nurses’ sta-
rent organizations supporting nursing informatics. tion in the hospital was viewed as the hub of information
exchange; therefore, numerous initial computer applica-
tions were developed and implemented in this location.
By the mid-1960s, clinical practice presented nurses
MAJOR HISTORICAL PERSPECTIVES with new opportunities for computer use. Increasingly
OF NURSING AND COMPUTERS complex patient care requirements and the prolifera-
tion of intensive care units (ICUs) required that nurses
Seven Time Periods
become super users of computer technology as nurses
Computers were introduced into the nursing profession monitored patients’ status via cardiac monitors and insti-
over 40 years ago. Major milestones of nursing are inter- tuted treatment regimens through ventilators and other
woven with the advancement of computer and informa- computerized devices such as infusion pumps. A signifi-
tion technologies, the increased need for nursing data, cant increase in time spent by nurses documenting patient
development of nursing applications, and changes mak- care, in some cases estimated at 40%, as well as a noted rise
ing the nursing profession an autonomous discipline. The in medication administration errors prompted the need to
key activities and events for each decade are presented investigate emerging hospital computer-based informa-
to provide a background and the sequence of events to tion systems (Sherman, 1965; Wolkodoff, 1963).

ch01.indd 4 22-10-2020 03:11:52

ch01.indd 5

TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

1973 First Invitational Conference: Management National League for Nursing (NLN) and Goldie Levenson (NLN)
Information Systems (MISs) for Public and Division of Nursing, Public Health Virginia K. Saba (DN/PHS)
Community Health Agencies Service (DN/PHS), Arlington, VA
1974 to 1975 Five Workshops in USA on MISs for Public and NLN and DN/PHS, selected US Cities Goldie Levenson (NLN)
Community Health Agencies Virginia K. Saba (DN/PHS)
1976 State-of-the-Art Conference on Management for NLN and DN/PHS, Washington, DC Goldie Levenson (NLN)
Public and Community Health Agencies Virginia K. Saba (DN/PHS)
1977 First Research: State-of-the-Art Conference on University of Illinois College of Nursing, Harriet H. Werley (UIL)
Nursing Information Systems Chicago, IL Margaret Grier (UIL)
1977 First undergraduate academic course: Computers The State University of New York at Judith Ronald (SUNY, Buffalo)
and Nursing Buffalo, Buffalo, NY
1979 First Military Conference on Computers in Nursing TRIMIS Army Nurse Consultant Team, Dorothy Pocklington (TRIMIS Army)
Walter Reed Hospital, Washington, DC Linda Guttman (ANC)
1980 First Workshop: Computer Usage in Healthcare University of Akron, School of Nursing, Virginia Newbern (UA/SON)

Chapter 1 • Historical Perspectives of Nursing Informatics

Continuing Education Department, Dorothy Pocklington (TRIMIS Army)
Akron, OH
Virginia K. Saba (DN/PHS)
1980 First Computer Textbook: Computers in Nursing Nursing Resources, Boston, MA Rita Zielstorff, Editor
1981 First Special Interest Group Meeting on Computers in Annual SCAMC Conference Event, Virginia K. Saba, Chair (DN/PHS)
Nursing at SCAMC Washington, DC
1981 to 1991 First Nursing Papers at Fifth Annual Symposium on Annual SCAMC Conference Sessions, Virginia K. Saba (DN/PHS)
Computer Applications in Medical Care (SCAMC) Washington, DC Coralee Farlee (NCHSR)
1981 to 1984 Four National Conferences: Computer Technology NIH Clinical Center, TRIMIS Army Nurse Virginia K. Saba (DN/PHS)
and Nursing Consultant Team, and DN/PHS NIH Ruth Carlson and Carol Romano (CC/NIH)
Campus, Bethesda, MD
Dorothy Pocklington and Carolyn Tindal
(TRIMIS Army) Transport Research and
Innovation Monitoring and Information
System Army
1981 Early academic course on Computers in Nursing Foundation for Advanced Education in Virginia K. Saba (DN/PHS)
(NIH/CC) Sciences (FAES) at NIH, Bethesda, MD Kathleen A. McCormick (NIH/PHS)
1982 Study Group on Nursing Information Systems University Hospitals of Cleveland, Case Mary Kiley (CWS)
Western Reserve University, and Gerry Weston (NCHSR)
National Center for Health Services
22-10-2020 03:11:52

Research (NCHSR/PHS), Cleveland, OH

(continued)

5
ch01.indd 6

6
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

P art 1 • N ursing I nformatics T echnologies

1982 to 2013 Initiated Annual International Nursing Rutgers, State University of New Jersey, College of Gayle Pearson (Rutgers)
Computer Technology Conference Nursing, CE Department, selected cities Jean Arnold (Rutgers)
Mary Anne Rizzolo
1982 First International Workshop: The Impact of London Hospital, UK and IFIP-IMIA, Harrogate, UK Maureen Scholes (UK)
Computers on Nursing Barry Barber (UK)
1982 First Newsletter: Computers in Nursing School of Nursing, University of Texas at Austin, Gary Hales (UT)
Austin, TX
1982/1984 Two Boston University (BU) Workshops on Boston University School of Nursing, Boston, MA Diane Skiba (BU)
Computers and Nursing
1982 PLATO IV CAI Educational Network System University of Illinois School of Nursing, Chicago, IL Pat Tymchyshyn (UIL)
1982 Capital Area Roundtable in Informatics in Greater Washington, DC Founding Members:
Nursing (CARING) Founded Susan McDermott
P.J. Hallberg
Susan Newbold
1983 to Present Initiated nursing papers at MEDINFO 1983—Amsterdam, NL Elly Pluyter-Wenting, First Nursing Chair
(Every 3 Years) World Congress on Medical Informatics, 1986—Washington, DC, USA
International Medical Informatics
1989—Singapore, Malaysia
Association (IMIA)
1992—Geneva, Switzerland
1995—Vancouver, Canada
1998—Seoul, South Korea
2001—London, United Kingdom
2004—San Francisco, CA, United States
2007—Brisbane, Australia
2010—Capetown, South Africa
2013—Copenhagen, Denmark
2015—São Paulo, Brazil
2017—Hangzhou, China
2019—Lyon, France
2021—Sydney, Australia
1983 Second Annual Joint SCAMC Congress and SCAMC and IMIA, San Francisco, CA and Virginia K. Saba, Nursing Chair
IMIA Conference Baltimore, MD
1983 Early Workshop: Computers in Nursing University of Texas at Austin, Austin, TX Susan Grobe (UT—Austin)
1983 First Hospital Workshop: Computers in St. Agnes Hospital for HEC, Baltimore, MD Susan Newbold
Nursing Practice
22-10-2020 03:11:53

1983 First: Nursing Model for Patient Care and TRIMIS Program Office, Washington, DC Karen Rieder (NNC)
Acuity System Dena Nortan (NNC)
ch01.indd 7

1983 to 2012 Initiated International Symposium: 1983—Amsterdam, Netherlands 1983—Maureen Scholes, First Chair
Nursing Use of Computers and 1985—Calgary, Canada 1985—Kathryn J. Hannah and Evelyn J.
Information Science, International Guillemin
Medical Informatics Association
(IMIA) Working Group 8 on Nursing
Informatics (NI).
2008 to 2014 Renamed: IMIA Nursing Informatics, 1988—Dublin, Ireland Noel Daley and Maureen Scholes
2014 to Present Special Interest Group (IMIA/NI-SIG) 1991—Melbourne, Australia Evelyn S. Hovenga and Joan Edgecumbe
(Q 2 Years)
1994—San Antonio, TX, USA Susan Grobe and Virginia K. Saba
1997—Stockholm, Sweden Ulla Gerdin and Marianne Tallberg
2000—Auckland, New Zealand Robyn Carr and Paula Rocha
2003—Rio de Janeiro, Brazil Heimar Marin and Eduardo Marques
2006—Seoul, Korea Hyeoun-Ae Park
2009—Helsinki, Finland Anneli Ensio and Kaija Saranto
2012—Montreal, Canada Patricia Abbott (JHU)
2014—Taipei, Taiwan Polun Chang
2016—Geneva, Switzerland Patrick Weber

Chapter 1 • Historical Perspectives of Nursing Informatics

2018—Guadlajara, Mexico Diane Skiba.
2021—Sidney, Australia Judy Murphy
1984 American Nursing Association (ANA) ANA Harriet Werley, Chair
Initiated First Council on Computer First Exec. Board:
Applications in Nursing (CCAN) Ivo Abraham
Kathleen McCormick
Virginia K. Saba
Rita Zielstorff
1984 First Seminar: Microcomputers for Nurses University of California at San Francisco, College William Holzemer, Chair
of Nursing, San Francisco, CA
1984 First Nursing Computer Journal: JB Lippincott, Philadelphia, PA Gary Hales (UT Austin)
Computers in Nursing CIN, Renamed First Editorial Board:
Computers, Informatics, Nursing Patricia Schwirian (OSU)
Virginia K. Saba (GT)
Susan Grobe ( UT)
Rita Zielstorff (MGH Lab)
1984 to 1995 First Annual Directory of Educational Software Christine Bolwell and National League for Nursing Christine Bolwell
for Nursing (NLN)

(continued)
22-10-2020 03:11:53

7
ch01.indd 8

8
P art 1 • N ursing I nformatics T echnologies
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

1985 NLN initiated First National Forum: National League for Nursing, New York City, NY Susan Grobe, Chair
Computers in Healthcare and Nursing First Exec. Board:
Diane Skiba
Judy Ronald
Bill Holzemer
Roy Simpson
Pat Tymchyshyn
1985 First Annual Seminar on Computers and NYU Medical Center, NY, NY Patsy Marr New York University (NYU)
Nursing Practice Janet Kelly (NYU)
1985 First Invitational Nursing Minimum Data University of Illinois School of Nursing, Chicago, IL Harriet Werley (UIL)
Set (NMDS) Conference Norma Lang (UM)
1985 Early academic course: Essentials of Georgetown University School of Nursing, Virginia K. Saba (GU)
Computers, in Undergraduate and Washington, DC
Graduate Programs
1985 to 1990 Early 5-year Project: Continuing Nursing Southern Regional Education Board (SREB), Eula Aiken (SREB)
Education: Computer Technology, Focus: Atlanta, GA
Nursing Faculty
1985 First Test Authoring Program (TAP) Addison-Wesley Publishing, New York, NY William Holzemer (UCSF)
1985 First Artificial Intelligence System for Creighton On-line Multiple Medical Education Sheila Ryan, Dean and Faculty Professor,
Nursing Services (COMMES), Creighton University Steven Evans, Developer
1986 Two early Microcomputer Institutes for Georgetown University, School of Nursing, Virginia K. Saba (GU)
Nurses Washington, DC Dorothy Pocklington (USL)
University of Southwest Louisiana Nursing Diane Skiba (BU)
Department, Lafayette, LA
1986 Established first nurse educator’s newslet- Christine Bolwell and Stewart Publishing, Christine Bolwell, Editor
ter: Micro World Alexandria, VA
1986 CIN First Indexed in MEDLINE and CINAHL J. B. Lippincott Publisher, Philadelphia, PA Gary Hales, Editor
1986 First NI Pyramid—NI Research Model Published in CIN Indexed in MEDLINE and CINAHL Patricia Schwirian (OSU)
1987 Initiated and Created Interactive Videodisc American Journal of Nursing, New York, NY Mary Ann Rizzolo (AJN)
Software Programs
1987 International Working Group Task Force on IMIA/NI Working Group 8 and Swedish Ulla Gerdin (NI)
Education Federation, Stockholm, Sweden Kristina Janson Jelger and Hans Peterson
(Swedish Federation)
22-10-2020 03:11:53
ch01.indd 9

1987 Videodisc for Health Conference: Stewart Publishing, Alexandria, VA Scott Stewart, Publisher
Interactive Healthcare Conference
1988 Recommendation #3: Support Automated National Commission on Nursing Implementation Vivian DeBack, Chair
Information Systems. Project (NCNIP), Secretary’s Commission on
Nursing Shortage
1988 Priority Expert Panel E: Nursing Informatics National Center for Nursing Research, National Judy Ozbolt, Chair
Task Force Institutes of Health, Bethesda, MD
1988 First Set of Criteria for Vendors ANA (American Nurses Association/Council on Mary McHugh
Nursing Science)/CANS Chair
Rita Zielstorff
Jacqueline Clinton
1989 Invitational Conference: Nursing National Commission on Nursing Implementation Vivian DeBack, Chair
Information Systems, Washington, DC Project (NCNIP), ANA, NLN, and NIS Industry
1989 to Present Initiated First Graduate Programs with University of Maryland School of Nursing, Barbara Heller, Dean
Specialty in Nursing Informatics, Baltimore, MD Program Chairs: Carol Gassert, Patricia
Master’s and Doctorate Abbott, Kathleen Charters, Judy Ozbolt,
and Eun-Shim Nahm
1989 to 2009 Virtual Learning Resources Fuld Institute for Technology in Nursing Julie McAfoos, Pioneer Software Developer.
Education (FITNE)

Chapter 1 • Historical Perspectives of Nursing Informatics

1989 ICN Resolution Initiated Project: International Council of Nurses Conference, Fadwa Affra (ICN)
International Classification of Nursing Seoul, Korea
Practice (ICNP)
1990 to 1995 Annual Nurse Scholars Program (HBO) Healthcare Technology Company and Roy Simpson (HBO)
HealthQuest Corporation Diane Skiba (BU)
Judith Ronald (SUNY Buffalo)
1990 ANA House of Delegates Endorsed: ANA House of Delegates Harriet Werley (UM)
Nursing Minimum Data Set (NMDS) to
Define Costs and Quality of Care
1990 Invitational Conference: State-of-the-Art of NCNIP, Orlando, FL Vivian DeBack, Chair
Information Systems
1990 Renamed ANA: Steering Committee on ANA, Washington, DC Norma Lang, Chair
Databases to Support Nursing Practice Kathy Milholland Hunter (ANA)
1990 Task Force: Nursing Information Systems NCNIP, ANA, NLN, NIS Industry Task Force, Project Vivian DeBack, Chair
Hope, VA
1991 to 2001 First Annual European Summer Institute International Nursing Informatics Experts Jos Aarts and Diane Skiba (USA)
1991 First Nursing Informatics Listserv University of Massachusetts, Amherst, MA Gordon Larrivee
1991 Formation of Combined Annual SCAMC AMIA/SCAMC Sponsors, Washington, DC Judy Ozbolt, First Chair
22-10-2020 03:11:53

Special Nursing Informatics Working

Group and AMIA NIWG
(continued)

9
ch01.indd 10

10
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

P art 1 • N ursing I nformatics T echnologies

1991/1992 Two WHO Workshops: Nursing Informatics World Health Organization and US PHS, Marian Hirschfield (WHO)
Washington, DC, and Geneva, Switzerland Carol Romano (PHS)
1991 to Present Initiated Annual Summer Institute in University of Maryland School of Nursing (SON), Program Chairs: Carol Gassert,
Nursing Informatics (SINI) Baltimore, MD Mary Etta Mills,
Judy Ozbolt, and Marisa Wilson
1992 ANA Approved Nursing Informatics as a ANA Database Steering Committee, Washington, Norma Lang, Chair
New Nursing Specialty DC
1992 Formation of Virginia Henderson Sigma Theta Tau International Honor Society, Judith Graves, Director
International Nursing Library (INL) Indianapolis, IN
1991/1992 ANA “Recognized” Four Nursing ANA Database Steering Committee, Washington, Norma Lang, Chair
Terminologies: Clinical Care DC
Classification (CCC) System, OMAHA
System, NANDA (North American
Nursing Diagnosis Association)
and (NIC) Nursing Intervention
Classification
1992 Read Clinical Thesaurus Added Nursing Read Codes Clinical Terms, Version 3 Ann Casey (UK)
Terms in UMLS/NLM
1992 Canadian Nurses Association: Nursing Canadian Nurses Association, Edmonton, Alberta, Phyllis Giovannetti, Chair
Minimum Data Set Conference Canada
1992 American Nursing Informatics Association Southern, CA Melodie Kaltenbaugh
(ANIA) Founded Constance Berg
1993 Four ANA “Recognized” Nursing ANA Database Steering Committee and NLM Norma Lang, Chair
Terminologies Integrated into UMLS Betsy Humphreys (NLM)
1993 Initiated Virginia Henderson Electronic Sigma Theta Tau International Honor Society, Carol Hudgings, Director
Library Online via Internet Indianapolis, IN
1993 Initiated AJN Network Online via Internet American Journal of Nursing Company, New York, Mary Ann Rizzolo, Director
NY
1993 ANC Postgraduate Course: Computer Army Nurse Corps, Washington, DC Army Nurse Corps (ANC)
Applications for Nursing
1993 Formation: Nursing Informatics Fellowship Partners Healthcare Systems, Wellesley, MA Rita Zielstorff, Director
Program
1993 Alpha Version: Working Paper of (ICNP) International Council of Nurses, Geneva, Fadwa Affara (ICN)
International Classification of Nursing Switzerland
Practice
22-10-2020 03:11:53
ch01.indd 11

1993 Formed: Denver Free-Net University of Colorado Health Sciences Center, Diane Skiba (UC), Developer
Denver, CO
1993 Priority Expert Panel E: Nursing Informatics National Center for Nursing Research (NCNR/NIH), Judy Ozbolt, Chair
Report: Nursing Informatics: Enhancing Bethesda, MD
Patient Care
1994 ANA-NET Online American Nurses Association, Washington, DC Kathy Milholland (ANA)
1994 Four Nursing Educators Workshops on Southern Council on Collegiate Regional Eula Aiken (SREB)
Computers in Education Education and University of Maryland, Mary Etta Mills (UMD)
Washington, DC; Baltimore, MD; Atlanta, GA;
Augusta, GA
1994 Next Generation: Clinical Information Tri-Council for Nursing and Kellogg Foundation, Sheila Ryan, Chair
Systems Conference Washington, DC
1994, 2008, and First Nursing: Scope and Standards of ANA Database Steering Committee Kathy Milholland (ANA), Carol Bickford (ANA)
2014 Nursing Informatics Practice
1995 First International NI Teleconference: Three International NI Experts: Sue Sparks (USA)
Countries Linked Together Nursing Informatics, USA Evelyn Hovenga (AU)
Health Information System, Australia Robyn Carr (NZ)

Chapter 1 • Historical Perspectives of Nursing Informatics

Nursing informatics, New Zealand
1995 First Combined NYU Hospital and NYU NYU School of Nursing and NYU Medical Center, Barbara Carty, Chair
SON: Programs on Nursing Informatics New York, NY Janet Kelly, Co-Chair
and Patient Care: A New Era
1995 First Weekend Immersion in NI (WINI) CARING Group, Warrenton, VA Susan Newbold (CARING)
Carol Bickford (ANA)
Kathleen Smith (USN Retired)
1995 First CPRI Davies Recognition Awards of Computer-Based Patient Record Institute, Los Intermountain Healthcare, Salt Lake City, UT
Excellence Symposium Angeles, CA Columbia Presbyterian MC, New York, NY
Department of Veterans Affairs, Washington,
DC
1995 Initiated CARING Web site CARING Susan Newbold (CARING)
Marina Douglas
1995 First ANA Certification in Nursing ANA Credentialing Center (ANCC) Rita Zielstorff (Chair)
Informatics
1996 ANA Established Nursing Information and ANA Database Steering Committee, Rita Zielstorff, Chair
Data Set Evaluation Center (NIDSEC) Washington, DC Carol Bickford
Connie Delaney, Co-Chair
22-10-2020 03:11:53

(continued)

11
ch01.indd 12

12
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)
Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

P art 1 • N ursing I nformatics T echnologies

1996 First Online Nursing Wichita State University, Wichita, KS Mary McHugh
Informatics Course Associate Professor
1996–1997 Nightingale Project—Health Telematics University of Athens, Greece, and European Union John Mantas, Chair (Greece)
Education, Three Workshops and Two Arie Hasman, Co-Chair (Netherlands)
International Conferences
Consultants:
Virginia K. Saba (USA)
Evelyn Hovenga (AU)
1996 Initiated TELENURSE Project Danish Institute for Health and Nursing Research Randi Mortensen, Director
and European Union Gunnar Nielsen, Co-Director
1996 First Harriet Werley Award for Best Nursing AMIA-NI Working Group (NIWG), Washington, DC Rita Zielstorff (MGH Computer Lab) First
Informatics Paper at AMIA Awardee
1997 Invitational National Nursing Informatics National Advisory Council on Nurse Education Carol Gassert, Chair
Workgroup and Practice and DN/PHS
1997 ANA Published NIDSEC Standards and ANA Database Steering Committee Rita Zielstorff, Chair
Scoring Guidelines Connie Delaney, Co-Chair
1997 National Database of Nursing Quality American Nurses Association Nancy Dunton, PI
Indicators (NDNQI®)
1997 Initiated Nursing Informatics Archival NLM—History Collection Virginia K. Saba, Chair (GT)
Collection
1998 Initiated NursingCenter.com Web site JB Lippincott, New York, NY Maryanne Rizzalo, Director
1999 Beta Version: ICNP Published International Council of Nurses, Geneva, Fadwa Affara (ICN)
Switzerland
1999 to 2008 Annual Summer Nursing Terminology Vanderbilt University, Nashville, TN Judy Oxbolt, Chair
Summit Suzanne Bakken, Program Chair
1999 Convergent Terminology Group for Nursing SNOMED/RT International, Northbrook, IL Suzanne Bakken, Chair (NYU), and Debra
Konicek (CAP)
1999 and 2004 United States Health Information Department of Defense (Health Affairs), CMS, Luann Whittenburg (OASD/HA)
Knowledgebase (USHIK) Integrated CDC, AHRQ Glenn Sperle (CMS)
Nursing Data
M. Fitzmaurice (AHRQ)

1999 Inaugural Virtual Graduation: Online Post- GSN, Uniformed Services University Faye Abdellah (USU)
Masters: ANP Certificate Program VA Tele-Conference Network, Bethesda, MD Virginia K. Saba (USU)
Eight Nationwide VA MCs Charlotte Beason (VA)
22-10-2020 03:11:53
ch01.indd 13

1999 First Meeting: Nursing Data Standards Project Pan American Health Organization (PAHO), Roberto Rodriquez (PAHO)
for Central Organization (PAHO) and Brazil Washington, DC Heimar Marin (Brazil)
2000 First, Director of Professional Services Healthcare Information Management System Joyce Sensmeier
Society (HIMSS)
2000 ICNP Programme Office Established International Council of Nurses, Geneva, Amy Coenen, First Nursing Director
Switzerland
2000 Computer-Based Patient Record Institute CPRI, Los Angeles, CA Virginia K. Saba, Nursing Chair
(CPRI) 2000 Conference
2001 AMIA’s Nursing Informatics Leaders University of Wisconsin, Madison, WI Pattie Brennan, President
Columbia University, New York, NY Suzanne Bakken, Program Chair
2002 ICNP Strategic Advisory Group Established ICN, Geneva, Switzerland Amy Coenen, Director
2002 Conference: Strategy for Health IT and Medical Records Institute (MRI), Boston, MA Peter Waegemann, President
eHealth Vendors
2002 AAN Conference: Using Innovative American Academy of Nursing, Washington, DC Margaret McClure, Chair
Technology Linda Bolton, Co-Chair
Nellie O’Gara, Co-Chair
2002 Initiated AAN Expert Panel on Nursing American Academy of Nursing Annual Virginia K. Saba, Co-Chair
Informatics Conference, Naples, FL Ida Androwich, Co-Chair

Chapter 1 • Historical Perspectives of Nursing Informatics

2003 Finnish Nursing Informatics Symposium Finnish Nurses Association (FNA) and Siemens Kaija Saranto (FN)
Medical Solutions, Helsinki, Finland Anneli Ensio (FN)
Rosemary Kennedy (Siemens)
2003 First ISO-Approved Nursing Standard: IMIA/NI-SIG and ICN, Oslo, Norway Virginia K. Saba, Chair (NI/SIG)
Integrated Reference Terminology Model Kathleen McCormick, Co-Chair (NIWG)
for Nursing
Amy Coenen, Co-Chair (ICN)
Evelyn Hovenga, Co-Chair (NI/SIG)
Susanne Bakken, Chair, Tech. Group
2004 First ICN Research and Development Deutschsprachige ICNP, Freiburg, Germany Peter Koenig, Director
Centre
2004 to Present Initiated Annual Nursing Informatics HIMSS Annual Conference, Orlando, FL Joyce Sensmeier, First Chair
Symposium at (HIMSS) Health
Information Management Systems
Society Conference and Exhibition
2004 Initial Formation of Alliance for Nursing AMIA/HIMSS Connie Delaney, Chair
Informatics (ANI) Joyce Sensmeier, Co-Chair
2004 to 2012 First Nurse on (NCHVS) National Center NCVHS, Washington, DC Judy Warren, KUMC
for Vital Health Statistics Standards
22-10-2020 03:11:53

Subcommittee
(continued)

13
ch01.indd 14

14
TABLE 1.1 Landmark Events and Pioneers in Computers and Nursing, and Nursing Informatics (continued)

P art 1 • N ursing I nformatics T echnologies

Year(s) Title/Event Sponsor(s) Coordinator/Chair/NI Representative(s)

2004 Office of the National Coordinator for National Coordinators First Coordinator:
Health Information Technology (ONC) Dr. David Brailer
Established
Dr. Robert Kolodner
Dr. David Blumenthal
Dr. Farzad Mostashari
Dr. Karen DeSalvo,
Nominated Directors.
2004 Technology Informatics Guiding Education National Members Marion Ball, Chair
Reform (TIGER)—Phase I Online Teleconferences Diane Skiba, Co-Chair
2006 First TIGER Summit 100 Invited Representatives from 70 Healthcare Marion Ball, Chair
Organizations; Summit Held at USU, Bethesda, Diane Skiba, Co-Chair
MD
2006 Revitalized NI Archival Collection—Initiated AMIA/NIWG Executive Committee Kathleen McCormick, Chair
Solicitation of Pioneer NI Documents Bonnie Westra, Co-Chair
Virginia K. Saba, Consultant
2005/2008/2009 ICNP Version 1.0, Version 1.1, and Version 2 ICN, Geneva, Switzerland Amy Coenen, Director
2006/2008 Symposium on Nursing Informatics Brazil Medical Informatics Society Heimar Marin, Chair
2007/2008 First National Nursing Terminology (ANSI-HITSP)American National Standards Virginia K. Saba and Colleagues, HITSP
Standard: Clinical Care Classification Institute’ and ‘Healthcare Information Committee Developers
(CCC) System Technology System Panel: Bio-surveillance
Committee HITSP Recommended and HHS
Secretary Approved
2007 to Present ANIA/CARING Joint Conferences Las Vegas, Washington, DC Victoria Bradley, Initial Chair
2009 to Present American Recovery and Reinvestment Act ONC National Health Information Technology Focus on Hospital HIT/EHR (Healthcare
of 2009—Health Information Technology Committee: Information Technology/Electronic
for Economic and Clinical Health (HITECH Healthcare Records) Systems Integrated
Act of 2009); ONC Formed Two National and Interoperable Terminology Standards
Committees, Each with One Nurse Health Policy Committee Judy Murphy, (Aurora Health Systems, MI)
Health Standards Committee Connie Delaney (UMN):
2009 ICNP recognized by WHO as First ICN and WHO, Geneva, Switzerland Amy Coenen, Director
International Nursing Terminology
2010 to Present Nursing Informatics Boot Camp Hospitals, Schools of Nursing, Vendors, Healthcare Susan K. Newbold, President
Member Organization
22-10-2020 03:11:53
ch01.indd 15

2010 Initiated: Doctor of Nursing Practice University of Minnesota, Minneapolis, MN Connie Delaney, Dean SON, UMN
Specialty in Informatics Bonnie Westra, Chair
2010 American Nursing Informatics Association ANIA and CARING Victoria Bradley, First President
(ANIA and CARING) Merged
2011 Tiger Initiative Foundation Incorporated TIGER Initiative Patricia Hinton Walker, Chair
2011 First Nurse as Deputy National Office of the National Coordinator (ONC) Judy Murphy
Coordinator for Programs & Policy at the
Office of the National Coordinator for
Health IT (ONC)
2012 to Present ANIA New Re-Named and First Annual ANIA with merged CARING Victoria Bradley, President
ANIA Conference Patricia Sengstack, President (2013/2014)
2013 First NI Nurse to be President of IMIA IMIA Hyeoun-Ae Park
Seoul National University, Seoul, Korea
2013 to 2019 Clinical Care Classification (CCC) System Hospital Corp of America (HCA) Nashville, TN Virginia K. Saba Chair Jane Englebright
(Q2 years) User Meetings Co-Chair
2013 to Present Nursing Knowledge Big Data Science University of Minnesota School of Nursing Connie Delaney, Chair
Initiative Annual Conferences Bonnie Westra

Chapter 1 • Historical Perspectives of Nursing Informatics

Co-Chair
2014 Collection of NI Artifacts Donated to University of Texas School of Biomedical Juliana and Jack Brixey
McGovern Historic Center Informatics
2016 First NI Nurse Director of National Library National Library of Medicine Patricia Brennen
of Medicine (NLM)
2016-2020 IMIA/NI-SIG Chair NI Expert - UC Diane Skiba, Chair
2019 Transfer CCC System to Hospital Corp of Nashville, TN Virginia K. Saba, CCC CNO & President ‘to’
America (HCA) Jane Englbright Senior VP & Chief Nursing
Executive , HCA
Jane Englebright, Senior VP & Chief Nursing
Executive, HCA
2020 7th Edition: Essentials of Nursing McGraw-Hill Publishing Virginia K. Saba, Co-Author
Informatics Kathleen McCormick, Co-Author
2021 MEDINFO / Combined IMIA and IMIA/ Sidney, Australia Australian NI
NI-SIG)
22-10-2020 03:11:54

15
 16 P art 1 • N ursing I nformatics T echnologies

TABLE 1.2 Nursing Knowledge Big Data Science Workgroups

Trendw Explanation/Example

Care Coordination Identify shareable and comparable data across settings to support care
coordination activities and improve patient outcomes.
Clinical Data Analytics Demonstrate the value of sharable and comparable nurse-sensitive data
to support practice and translational research for transforming health
care and improving patient quality and safety.
Context of Care Develop the test Big Data set using the Kruchten 4+1 Model and Unified
Modeling Language (UML) to introduce an integrating and harmonizing
framework for sharable and comparable nurse data across the care con-
tinuum that incorporates the Nursing Minimum Management Data Set
(NMMDS) and links key Workgroup activities.
Education Strengthen informatics education at the graduate and specialty levels and
the ability of educators who teach informatics to nursing student so
that we can achieve the outcomes of shareable and comparable nursing
data through the work of nurses at the point of care.
Encoding and Modeling Develop and disseminate LOINC and SNOMED Clinical Terms for electronic
health record nursing assessments, and incorporate them into a frame-
work and repository for dissemination.
Engage and Equip All Nurses in Health IT Policy Equip nurses with education, tools, and resources and engage them as
knowledgeable advocates for health IT policy efforts important to
nursing.
E-Repository Develop and implement a repository designed to collect nursing infor-
matics best evidence in the form of documents, surveys, instruments,
algorithms, for example.
Mobile Health Explore the use of mobile health tools and data for nurses including both
nursing-generated data and patient-generated data. Identify and sup-
port activities and resources to address unmet needs and create oppor-
tunities to utilize mHealth data within nursing workflows.
Nursing Value Measure the value of nursing care as well as the contribution of individual
nurses to clinical outcomes and cost. Develop big data techniques for
secondary data analysis that will provide metrics to monitor quality,
costs, performance, effectiveness, and efficiency of nursing care.
Social Determinants of Health Support the inclusion, interoperability, and data exchange of Social
Determinants of Health (SDOH) data in electronic health records, per-
sonal and m-health tools, and community and public health portals
across care settings. Empower nurses (practice, education, research, pol-
icy) to use SDOH data as context for planning care. Develop a roadmap
to engage nurses to improve population health through large-scale
adoption of SDOH.
Transforming Documentation Explore ways to decrease the nursing documentation burden and serve
up the information already in the electronic health record at the right
time in the workflow to support evidence-based and personalized care.
Elevate purpose-driven, role-based, patient-centric, evidence-informed
documentation transformation to capture nurse observations and inter-
ventions, and drive purposeful secondary-use and precision nursing.

ch01.indd 16 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics 17

1970s During the late 1960s through the 1970s, hospitals federal agencies (Public Health Service, Army Nurse
began developing computer-based information systems Corps) and several university schools of nursing provided
which initially focused on computerized physician order educational conferences and workshops on the state-of-
entry (CPOE) and results reporting; pharmacy, labora- the-art regarding computer technology and its influence
tory, and radiology reports; information for financial and on nursing. During this time, the Clinical Center at the
managerial purposes; and physiologic monitoring systems National Institutes of Health implemented the Technicon
in the intensive care units; and a few systems started to Data System (TDS) system; one of the earliest clinical
include care planning, decision support, and interdisci- information systems (called Eclipsys & Allscripts) was the
plinary problem lists. While the content contained in early first system to include nursing practice protocols.
hospital information systems frequently was not specific to In addition to the use of computers, advancement was
nursing practice, a few systems did provide a few pioneer underway for other technologies and/or devices used by
nurses with a foundation on which to base future nurs- nurses. For example, the first point-of-care blood glucose
ing information systems (Blackmon et al., 1982; Collen, monitor became available for use in the clinical setting in
1995; Ozbolt & Bakken, 2003; Romano, McCormick, & 1970 (Clarke & Foster, 2012). The devices became smaller
McNeely, 1982). Regardless of the focus, which remained and more widespread in the 1980s.
primarily on medical practice, nurses often were involved
in implementing health information technology (HIT) 1980s In the 1980s, the field of nursing informatics
systems. exploded and became visible in the healthcare industry
Interest in computers and nursing began to emerge and nursing. Technology challenged creative profession-
in public health, home health, and education during the als in the use of computers in nursing. As computer sys-
1960s to 1970s. Automation in public health agencies tems were implemented, the needs of nursing took on a
began as a result of pressure to standardize data collec- cause-and-effect modality; that is, as new computer tech-
tion procedures and provide state-wide reports on the nologies emerged and as computer architecture advanced,
activities and health of the public (Parker, Ausman, & the need for nursing software evolved. It became apparent
Ovedovitz, 1965). In the 1970s, conferences sponsored that the nursing profession needed to update its practice
by the Division of Nursing (DN), Public Health Service standards and determine specific data standards, vocabu-
(PHS), and the National League for Nursing (NLN) helped laries, and classification schemes that could be used for
public health and home health nurses understand the the computer-based patient record systems.
importance of nursing data and their relationship to new In the 1980s, the microcomputer or personal computer
Medicare and Medicaid legislation requirements passed (PC) emerged. This revolutionary technology made com-
in 1966. The conferences provided information on the puters more accessible, affordable, and usable by nurses
usefulness of computers for capturing and aggregating and other healthcare providers. The PC brought comput-
home health and public health information. Additional ing power to the workplace and, more importantly, to the
government-sponsored conferences focused on educa- point of care. Also, the PCs served as dumb terminals
tional uses of computers for nurses (Public Health Service, linked to the mainframe computers and as stand-alone
1976). Simultaneously, hospitals and public health agen- systems (workstations). The PCs were user-friendly and
cies embarked on investigating computers and nursing; allowed nurses to design and program their own applica-
the opportunity to improve education using computer tions. The influence of computer technology extended to
technology commenced. Bitzer (1966) reported on one the introduction of devices to improve patient safety. For
of the first uses of a computerized teaching system called example, the automated dispensing cabinets (ADCs) were
PLATO, which was implemented to teach classes in off- introduced in the 1980s (Grissinger, 2012). The computer-
campus sites as an alternative to traditional classroom controlled ADCs replaced medication carts and drug floor
education. stock. Tracking of medications occurred at the point of
The early nursing networks, which were conceived care. The use of ADCs in the clinical setting has resulted
at health informatics organizational meetings, helped to in the reduction of medication errors.
expand nursing awareness of computers and the impact Starting in 1981, national and international confer-
HIT could have on practice. The state of technology ini- ences and workshops were conducted by an increasing
tially limited opportunities for nurses to contribute to the number of nursing pioneers to help nurses understand
HIT design, but as technology evolved toward the later part and get involved in this new emerging nursing specialty.
of the 1970s and as nurses provided workshops nationally, Also during the 1980s, invitational conferences were
nurses gained confidence that they could use computers conducted to develop nursing data sets and vocabular-
to improve practice. The national nursing organization’s ies as well as numerous workshops were conducted at

ch01.indd 17 22-10-2020 03:11:54

 18 P art 1 • N ursing I nformatics T echnologies

universities to introduce this new specialty into nursing quality of care (Shortliffe, Perreault, Wiederhold, & Pagan,
education. During this period, many mainframe health- 2003). Advances in relational databases, client-server
care information systems (HISs) emerged with nursing architectures, and new programming methods created the
subsystems. These systems documented several aspects opportunity for better application development at lower
of the patient record, namely, provider order entry and costs. Legislative activity in the mid-1990s paved the way
results reporting, the Kardex reporting, vital signs, and for EHRs through the Health Insurance Portability and
other systems-documented narrative nursing notes using Accountability Act (HIPAA) of 1996 (public-law 104-191),
word-processing software packages. Discharge planning emphasizing standardized transactions, and privacy and
systems were developed and used as referrals to commu- security of patient-identifiable information (Gallagher,
nity, public, and home healthcare facilities for the contin- 2010). The complexity of technology, workflow analysis,
uum of care. and regulations shaped new roles for nursing.
Nurses began presenting at multidisciplinary confer- In 1992, the ANA recognized nursing informatics as
ences and formed their own working groups within HIT a new nursing specialty with a separate Scope of Nursing
organizations, such as the first Nursing Special Interest Informatics Practice Standards, and also established a
Group on Computers which met for the first time dur- specific credentialing examination for it (ANA, 2008).
ing SCAMC (Symposium on Computer Applications in Numerous local, national, and international organiza-
Medical Care) in 1981. As medical informatics evolved, tions provided a forum for networking and continuing
nursing began focusing on what was unique about nursing education for nurses involved with informatics (Sackett &
within the context of informatics. Resolutions were passed Erdley, 2002). The demand for NI expertise increased in
by the American Nurses Association (ANA) regarding the healthcare industry and other settings where nurses
computer use in nursing and in 1985, the ANA approved functioned, and the technology revolution continued to
the formation of the Council on Computer Applications in impact the nursing profession.
Nursing (CCAN). One of the first activities the CCAN exec- The need for computer-based nursing practice stan-
utive board initiated was to solicit several early pioneers to dards, data standards, nursing minimum data sets, and
develop monographs on the status of computers in nursing national databases emerged concurrently with the need
practice, education, research, and management. The CCAN for a unified nursing language, including nomenclatures,
board developed a yearly Computer Nurse Directory on the vocabularies, taxonomies, and classification schemes
known nurses involved in the field, conducted computer (Westra, Delaney, Konicek, & Keenan, 2008). Nurse
applications demonstrations at the ANA annual confer- administrators started to demand that the HITs include
ences, and shared information with their growing members nursing care protocols and nurse educators continued to
in the first CCAN newsletter Input-Output. During this require the use of innovative technologies for all levels
time NI newsletters, journals, and several books, such as the and types of nursing and patient education. Also, nurse
first edition of this book Essentials of Computers for Nurses researchers required knowledge representation, deci-
published in 1986, were used for educational courses intro- sion support, and expert systems based on standards that
duced in the academic nursing programs, and workshops allowed for aggregated data (Bakken, 2006).
conducted on computers and nursing. The CCAN became In 1997, the ANA developed the Nursing Information
a very powerful force in integrating computer applications and Data Set Evaluation Center (NIDSEC) to evaluate and
into the nursing profession. In 1988, the CCAN commis- recognize nursing information systems (ANA, 1997). The
sioned three NI experts to prepare a set of criteria on the purpose was to guide the development and selection of
integration of nursing practice for EHR vendors to fol- nursing systems that included standardized nursing ter-
low (Zielstorff, McHugh, & Clinton, 1988). In 1989, the minologies integrated throughout the system whenever
ANA renamed the CCAN to the Steering Committee on it was appropriate. There were four high-level standards:
Databases to Support Clinical Nursing Practice, which later (a) inclusion of ANA-recognized terminologies; (b) link-
became the Committee for Nursing Practice Information ages among concepts represented by the terminologies
Infrastructure (CNPII). The purpose of the CNPII was to retained in a logical and reusable manner; (c) data included
support development and recognition of national health in a clinical data repository; and (d) general system char-
data standards (Coenen et al., 2001). acteristics. The Certification Commission for Health
Information Technology (CCHIT) had similar criteria
1990s By the 1990s, large integrated healthcare delivery for the EHR certification, which was later adopted by the
systems evolved, further creating the need for informa- Office of the National Coordinator for Health Information
tion across healthcare facilities within these large systems Technology (ONC); however, nursing data was no longer
to standardize processes, control costs, and assure the included. ANA was ahead of its time in its thinking and

ch01.indd 18 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics 19

development. The criteria are now under revision by the administration (BCMA) system was first implemented
ANA to support nurses to advocate their requirements for in 2000 in an acute care hospital to electronically cap-
the emerging HIT systems. ture medication management (Wideman, Whittler, &
Technology rapidly changed in the 1990s, increasing Anderson, 2005). The RFID also emerged to help nurses
its use within and across nursing units as well as across find equipment or scan patients to assure that all surgical
healthcare facilities. Computer hardware—PCs—con- equipment is removed from inside patients before surgi-
tinued to get smaller and computer notebooks were cal sites are closed (Westra, 2009). Smaller mobile devices
becoming affordable, increasing the types of computer with wireless or Internet access such as notebooks, tablet
technology available for nurses to use. Linking computers PCs, personal digital assistants (PDAs), and smart cellu-
through networks both within hospitals and health sys- lar telephones increased access to information for nurses
tems as well as across systems facilitated the flow of patient within hospitals and in the community. The development
information to provide better care. By 1995, the Internet and subsequent refinement of voice over Internet protocol
began providing access to information and knowledge (VoIP) provided voice cost-effective communication for
databases to be integrated into desktop computer systems. healthcare organizations.
It revolutionized information technologies. The Internet The Internet which appeared in 1995 provided a
moved into the mainstream social milieu with electronic means for the development of clinical applications. Also,
mail (e-mail), file transfer protocol (FTP), Gopher, and databases for EHRs could be hosted remotely on the
Telnet, and World Wide Web (WWW) protocols greatly Internet, decreasing costs of implementing EHRs. Remote
enhanced its usability and user-friendliness (Saba, 1996; monitoring of multiple critical care units from a single
Sparks, 1996). The Internet was used for high-performance site increased access for safe and effective cardiac care
computing and communication (HPCC) or the “informa- (Rajecki, 2008). Home healthcare increasingly partnered
tion superhighway” and facilitated data exchange between with information technology for the provision of patient
computerized patient record systems across facilities and care. Telehealth applications, a recognized specialty for
settings over time. The Internet led to improvements in nursing since the late 1990s, provided a means for nurses
networks, and a browser, WWW, allowed organizations to monitor patients at home and support specialty con-
to communicate more effectively and increased access to sultation in rural and underserved areas. The NI research
information that supported nursing practice. The WWW agenda promoted the integration of nursing care data in
also became an integral part of the HIT systems and the HIT systems that would also generate data for analysis,
means for nurses to browse the Internet and search world- reuse, and aggregation.
wide resources (Nicoll, 1998; Saba, 1995). A historical analysis of the impact of the Nursing
Minimum Data Set (NMDS) demonstrated that contin-
2000s A change occurred in the new millennium as more ued consensus and effort was needed to bring to fruition
and more healthcare information became digitalized and the vision and implementation of minimum nursing data
newer technologies emerged. In 2004 an executive order into clinical practice (Hobbs, 2011). The NMDS continues
13335 established the ONC and issued a recommendation to be the underlining focus in the newer HIT systems. A
calling for all healthcare providers to adopt interoperable new NI research agenda for 2008–2018 (Bakken, Stone, &
EHRs by at least 2014 or 2015 (http://healthhit.gocv/topic/ Larson, 2012) emerged as critical for this specialty. The
about-onc). This challenged nurses to get involved in the new agenda is built on the agenda originally developed and
design of systems to support their workflow as well as in published by the National Institute for Nursing Research
the integration of information from multiple sources to (NINR) in 1993 (NINR, 1993). The authors focused on
support nurses’ knowledge of technology. In the late 2000s, the new NI research agenda on “3 aspects of context—
as hospitals became “paperless,” they began employing genomic health care, shifting research paradigms and
new nurses who had never charted on paper. social (Web2.0) technologies” (p. 280).
Technological developments that influenced health- A combination of the economic recession along with
care and nursing included data capture and data sharing the escalating cost of healthcare resulted in the American
technological tools. Wireless, point of care, regional data- Recovery and Reinvestment Act (ARRA) of 2009 and
base projects, and increased IT solutions proliferated in the Health Information Technology for Economic and
healthcare environments, but predominately in hospitals Clinical Health (HITECH) Act of 2009 with funding to
and large healthcare systems. The use of bar coding and implement HIT and/or EHR systems, support health-
radiofrequency identification (RFID) emerged as a useful care information exchange, enhance community and
technology to match the “right patient with the right med- university-based informatics education, and support lead-
ication” to improve patient safety. A barcode medication ing edge research to improve the use of HIT (Gallagher,

ch01.indd 19 22-10-2020 03:11:54

 20 P art 1 • N ursing I nformatics T echnologies

2010). One of the first ONC initiatives was the Healthcare CMS began to focus reimbursement on a quality payment
Information Technology Standards Panel (HITSP) which program that addressed quality outcome measures (MIPS,
was designed to determine what coding systems were used 2019). It is anticipated that this initiative will also mini-
to process patient care data from admission to discharge. mize the payment burden on the clinicians by aggregating
It was found that the nursing care data was missing in the their patients’ health information from multiple providers
existing EHRs. Initially, in 2005–2007, the Clinical Care into a single electronic application.
Classification (CCC) System met the established stan- As of 2018, the CMS proposed policies to strengthen
dards as interoperable and was accepted and approved as Interoperability. The ONC and CMS rebranded MU to
the free, coded, nursing taxonomies that could be used for Promoting Interoperability. It is anticipated that the initia-
assessing and documenting nursing care to generate qual- tive will make use of new technologies and for patients to
ity outcomes (Saba & Whittenburg, 2015). This project aggregate their health information from multiple provid-
ended in 2009 when the HITECH Act of 2009 emerged. ers into a single electronic application. In 2019, the ONC
continued to implement the latest legislation as well as
2010s During 2010, the ONC convened two national Interoperability through summits, webinars, and public
committees, (a) National Committee on Health Policy and comment.
(b) National Committee on Health Standards, which out- Nurses have always been involved with all phases of
lined and designed to address the HITECH Act of 2009. MU as well as all other legislation, from the implemen-
The committees designed the “Meaningful Use” (MU) tation of systems to assuring usage and adaptation to the
program which was to be implemented in three stages of evolving health policy affecting the HIT and/or EHR sys-
legislation consisting of regulations which built onto each tems. Thus, the field of nursing informatics (NI) contin-
other with the ultimate goal of implementing a complete ues to grow due to the MU regulations which continue to
and interoperable EHR and/or HIT system in all U.S. hos- impact on every inpatient hospital in the country. To date,
pitals. For each stage, regulations were proposed by the the majority of hospitals in the country has established
national committees, developed and reviewed by the pub- HIT departments and has employed at least one nurse to
lic before they were finalized, and submitted to Centers for serve as a NI expert to assist with the implementation of
Medicare and Medicaid (CMS) and the healthcare facili- MU requirements. As the MU requirements changed they
ties for implementation. also impacted on the role of the NI experts in hospitals
In 2011–2012, MU Stage 1 was initiated focusing pri- and ultimately on the roles of all nurses in the inpatient
marily on the CPOE initiative for physicians. Hospitals and outpatient facilities making NI an integral component
that implemented this MU regulation successfully received of all professional nursing services. An example of nurs-
federal funds for their HIT systems. In 2013–2015, MU ing involvement is the implementation of the CCC System
Stage 2 was introduced focusing primarily on the imple- nursing terminologies for documenting nursing practice
mentation of quality indicators that required electronic in the Hospital Corp of American (HCA) healthcare facili-
data to be collected as an integral component in the HIT ties (Saba & Whittenburg, 2015).
systems. The quality indicators would be used to guide
hospitals in patient safety and if not implemented used
as indicators subject to financial penalties. The proposed
Electronic Health Record Systems from a
MU Stage 3 that focused on care quality outcome mea-
Historical Perspective
sures was not implemented but replaced by the Medicare
Access and CHIP Reauthorization Act (MACRA) of In 1989, the Institute of Medicine (IOM) of the National
2015. The MACRA legislation created a new Medicare Academy of Sciences convened a committee and asked
Quality Payment Program that prioritized the value of the question, “Why is healthcare still predominantly
healthcare received by Medicare beneficiaries and revised using paper-based records when so many new computer-
Medicare’s reimbursement to eligible providers. The legis- based information technologies are emerging?” (Dick &
lation consolidated components of the Physician Quality Steen, 1991). The IOM invited representatives of major
Reporting System (PQRS), Value-Based Payment Modifier stakeholders in healthcare and asked them to define the
(VBM), and the Medicare Electronic Health Record problem, identify issues, and outline a path forward. Two
(EHR) Incentive program into the Merit-Based Incentive major conclusions resulted from the committee’s delib-
Payment System (MIPS). The purpose of the MIPS pro- erations. First, computerized patient record (CPR) is an
gram, initiated in 2017, was to establish Medicare pay- essential technology for healthcare and is an integral tool
ment to healthcare professional’s performance score for all professionals. Second, the committee after hear-
based on a value-based healthcare model. As a result, the ing from numerous stakeholders recognized that there

ch01.indd 20 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics 21

was no national coordination or champion for CPRs. As professional nurses, and other healthcare professionals
a result, the IOM committee recommended the creation must be involved in the design and upgrades of EHRs.
of an independent institute to provide national leadership. Determination of “usability” does not end with design or
The Computer-Based Patient Record Institute (CPRI) was implementation but should continue into the post-imple-
created in 1992 and given the mission to initiate and coor- mentation evaluation process. The data collected can be
dinate the urgently needed activities to develop, deploy, used to inform future usability upgrades to the EHR.
and routinely use CPRs to achieve improved outcomes in
healthcare quality, cost, and access. Consumer-Centric Healthcare Systems Another impact
A CPRI work group developed the CPR Project of the escalating cost of healthcare is a shift toward a
Evaluation Criteria in 1993 modeled after the Baldridge consumer-centric healthcare system. Consumers are
Award. These criteria formed the basis of a self-assessment encouraged to be active partners in managing their per-
that could be used by organizations and outside review- sonal health. A variety of technologies have evolved to
ers to measure and evaluate the accomplishments of CPR enable consumers to have access to their health informa-
projects. The four major areas of the initial criteria— tion and choose whether to share this across healthcare
(a)management, (b) functionality, (c) technology, and providers and settings. Personal health records emerged
(d) impact—provided a framework through which to view as either stand-alone systems or those tethered to EHRs.
the implementation of computerized records. The crite- Consumers are increasing in healthcare information liter-
ria, which provided the foundation for the Nicholas E. acy as they demand to become more involved in managing
Davies Award of Excellence Program, reflect the nation’s their own health.
journey from paper-based to electronic capture of health
data. The Davies Award of Excellence Program evolved
through multiple revisions and its terminology updated Patient Portal
from the computerized patient record to the electronic A feature of the EHR is the patient portal which replaced
medical record (EMR), and more recently to the electronic the personal health record. The portal is a secure online site
health record (EHR). Today, under HIMSS management, where a patient accesses his or her health information as
the Davies Award of Excellence Program is offered in four well as communicates with his or her team of healthcare
categories: (1) Enterprise (formerly Organizational or providers. Access to the patient portal requires a user name
Acute Care), first offered in 1995; (2) Ambulatory Care, and password. The portal is accessible at anyplace and any-
started in 2003; (3) Public Health, initiated in 2004; and (4) time that the patient has access to the Internet. From the
Community Health Organizations (CHO), first presented portal, the patient can review a provider visit, laboratory
in 2008 (http://apps.himss.org/davies/index.asp). and radiology results, medications, and allergies.
Furthermore, a provider can message the patient with
Usability reminders for medical screenings, upcoming appoint-
ments, medication refills, and billing information. An
The usability of EHRs has received increasing attention due emerging feature of the patient portal is the e-visit. Using
to the widespread implementation in both inpatient and an e-visit, the patient can consult with a provider regard-
ambulatory care. As such, the positive and negative aspects ing a non-emergent health issue. The patient portal and
of EHR usability has been identified. Usability is defined personal health record are sometimes used interchange-
as “the extent to which a product can be used by specified ably. There is an important difference. The personal health
users to achieve specified goals with effectiveness, effi- record is patient controlled. No one can access including
ciency and satisfaction in a specified context of use” (Aydin providers unless given permission. In contrast, the patient
& Beruvides, 2014; ISO, 2010). The National Institute of portal is accessible to providers to upload information.
Standards and Technology (NIST) has been at the forefront
of the initiative to establish a framework that describes and
evaluates health information technology (NIST, n.d.). The Wearable Technology in Healthcare
initiative is in collaboration with the ONC and Agency for
Healthcare Research and Quality (AHRQ). The explosion of sensors has influenced the development
The Health Information Management Systems Society of consumer wearable products to track health and fitness
(HIMSS, 2019) has identified nine usability principles to parameters. Sensors are embedded in wearable devices
be used in the development and evaluation of an EHR. or fabrics to record heart rate and rhythm, respiration,
It is imperative that usability principles are used in the oxygen saturation, body temperature, hours of sleep, glu-
design of EHRs. Furthermore, end users of doctors, cose levels, and fitness activities. The consumer receives

ch01.indd 21 22-10-2020 03:11:54

 22 P art 1 • N ursing I nformatics T echnologies

real-time feedback for the device. The wearable may be archival documents from the NI pioneers. The history
synched with the consumer’s smartphone. Data collected project was initiated based on a recommendation by
by the device is consumer controlled and shared. Data can Dr. Morris Collen who published the history of medical
be shared with other consumers or with healthcare pro- informatics in 1995 (Collen, 1995). However, it was not
fessionals. There has not been widespread acceptance to until 2001 that the Nursing Informatics Working Group
store consumer-collected data in the EHR. The number of (NIWG) of the American Medical Informatics Association
wearable devices continues to increase with the progress (AMIA) became involved and the NI History Committee
in research and development activities of technology com- was established to lead the project. The committee solic-
panies and universities. ited archival material from the identified NI pioneers for a
history of NI to be housed in the NLM as part of its history
Nursing Knowledge Big Data Science Initiative collection.
Beginning in 2004, the rich stories of pioneers in NI
Nursing has a long history in informatics, developing were captured through a project sponsored by the AMIA-
HIT systems and data standards for capturing the prac- NIWG. The AMIA-NIWG History Committee developed
tice of nursing; however, there is a dearth of IT systems an evolving list of pioneers and contributors to the his-
that incorporate nursing data standards due to the lack of tory of NI. Pioneers were defined as those who “opened
regulatory requirements and financial incentives. In 2013, up” a new area in NI and provided a sustained contribu-
the University of Minnesota School of Nursing initiated a tion to the specialty (Newbold & Westra, 2009; Westra &
national collaborative, bringing together nurses from prac- Newbold, 2006). Through multiple contacts and review of
tice, education, research, software vendors, informatics the literature, the list grew to 145 pioneers and contribu-
organizations, and other professional and governmental tors who shaped NI since the 1950s. Initially, each identi-
agencies. Over the past 7 years, annual think-tank con- fied pioneer was contacted to submit their nonpublished
ferences were held to report out and plan activities for documents and/or historical materials to the National
11 virtual working groups to accomplish a national agenda Library of Medicine (NLM) to be indexed and archived
to achieve sharable and comparable nursing data to ensure for the Nursing Informatics History Collection.
the timely adoption of big data methodologies across all Approximately 25 pioneers submitted historical
of nursing’s domains (Delaney & Weaver, 2018). Table materials that were catalogued with a brief descrip-
1-2 describes the purpose of the 11 virtual workgroups. tion. Currently, the catalogued document descriptions
Proceedings and all supporting documents of over the past can be searched online: https://www.nlm.nih.gov/hmd/
7 years can be found at http://z.umn.edu/bigdata. manuscripts/accessions.html. The documents can be
The ANA approved a position statement that all set- viewed by visiting the NLM. Eventually, each archived
tings in which nurses work should adopt a free, coded, document will be indexed and available online in the NI
standardized nursing terminology such as the CCC History Collection. Also from the original list, a conve-
System; however, for interoperability the terminology stan- nience sample of pioneers was interviewed over a 4-year
dard should be mapped to SNOMED-CT (Systematized period at various NI meetings. Videotaped stories from
Nomenclature of Medicine–Clinical Terms) and LOINC 33 pioneers were recorded and are now available on the
(Logical Observation Identifiers Names and Codes). The AMIA Web site: https://www.amia.org/working-groups/
2019 ONC Interoperability Standard supports this posi- nursing-informatics/history-project.
tion, laying the foundation for future regulatory require-
ments (ONC, 2019). Backgrounds The early pioneers came from a variety of
backgrounds as nursing education in NI did not exist in the
1960s. Almost all of the pioneers were educated as nurses,
NURSING INFORMATICS PIONEERS with a few exceptions. A limited number of pioneers had
This section provides information specific to an ongoing additional education in computer science, engineering,
project describing the early pioneers that influenced and epidemiology, and biostatistics. Others were involved with
impacted on the integration of NI into the nursing profes- anthropology, philosophy, physiology, and public health.
sion including their significance. Their unique career paths influenced the use of technology
in health care. Some nursing faculty saw technology as a
way to improve education. Others worked in clinical set-
History Project
tings and were involved in “roll-outs” of information sys-
In 1995, Saba initiated a history of NI at the National tems. Often these systems were not designed to improve
Library of Medicine that consisted of the collection of nursing work, but the pioneers had a vision that technology

ch01.indd 22 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics 23

could make nursing practice better. Other pioneers gained health care. Pioneers by definition are nurses who forged
experience through research projects or working for soft- into the unknown and had a vision of what was possible,
ware vendors. The commonality for all the pioneers is even if they did not know how to get there. One of the
they saw various problems and inefficiencies in nursing, pioneers advised, “Don’t be afraid to take on something
and they had a burning desire to use technology to “make that you’ve never done before. You can learn how to do it.
things better.” The trick is in finding out who knows it and picking their
brain and if necessary, cornering them and making them
teach you!” Another said, “Just do it, rise above it [barri-
Videotaped Interviews The AMIA Nursing Informatics
ers], and go for it ‘you are a professional’, and you have to
History page contains a wealth of information. The 33 vid-
be an advocate for yourself and the patient.” Many of the
eotaped interviews are divided into two libraries. The full
pioneers described the importance of mentors, someone
interviews are available in Library 1: Nursing Informatics
who would teach them about informatics or computer
Pioneers. For each pioneer, a picture, short biographical
technology, but it was still up to them to apply their new
sketch, transcript of the interview, and an MP3 audio file
knowledge to improve nursing. Mentors were invalu-
are included in addition to the videotaped interview. In
able by listening, exchanging ideas, connecting to others,
Library 2: Themes from Interviews, selected segments
and supporting new directions. Networking was another
from the interviews are shared for easy comparison across
strong theme for pioneers. Belonging to professional orga-
the pioneers. The themes include the following:
nizations, especially interprofessional organizations, was
• Nursing informatics—what it is, present, future, key for success. At meetings, the pioneers networked and
what nursing brings to the table exchanged ideas, learning from others what worked and,
more importantly, what didn’t work. They emphasized the
• Significant events that have shaped the field of
importance of attending social functions at organizational
nursing informatics
meetings to develop solid relationships so they could call
• Pioneers’ paths—careers that lead up to on colleagues later to further network and exchange ideas.
involvement in (nursing) informatics Nursing informatics did not occur in a vacuum; a
• When nurses first considered themselves major effort was made to promote the inclusion of nurses
informatics nurses in organizations affecting health policy decisions such as
• Pioneers’ first involvement—earliest events they the ONC’s Technology Policy and Standards Committees.
recall The nursing pioneers influenced the evolution of informat-
ics as a specialty from granular-level data through health
• Informatics—its value, pioneers’ realizations of the
policy and funding to shape this evolving and highly vis-
value of informatics, how they came to understand
ible specialty in nursing.
the value of informatics
• Demography of pioneers including names,
educational backgrounds, and current positions
Recent History Committee Activities
• Personal aspirations and accomplishments, an
overall vision that guided the pioneers’ work, The NI History Project continues as an activity commit-
people the pioneer collaborated with to accomplish tee of the AMIA-NIWG. For more than 5 years, a new
their visions, and goals committee was formed with a new Chair—Juliana J.
Brixey. Their monthly meetings have led to several new
• Pioneers’ lessons learned that they would like to
initiatives to advance to the field. The committee devel-
pass on
ops yearly goals to align with AMIA-NIWG. Notable goals
The Web site also provides “use cases” for ideas about achieved include the following: reference list of keystone
how to use the information for teaching and learning more articles written by pioneers, a list of abstract biographies
about the pioneers. These resources are particularly useful for 11 pioneers not videotaped, an additional video library,
for courses in informatics, leadership, and research. They Computers in Nursing Series, and a biographical abstract
also are useful for nurses in the workforce who want to of Dr. Harriett Werley for the Web site.
learn more about NI history. Moreover, the committee members are dedicated to
the dissemination of knowledge through publications and
oral presentations to nurses in various venues. For exam-
Lessons Learned Pioneers have generously shared les- ple, Newbold has provided an overview of the pioneers at
sons learned from their work and use of technology in each of her nursing informatics boot camps and has been

ch01.indd 23 22-10-2020 03:11:54

 24 P art 1 • N ursing I nformatics T echnologies

an invited speaker for numerous nursing events. Also, advances confirmed the status of NI as a new ANA spe-
Newbold and Brixey have presented posters at various cialty in nursing and provided the stimulus to transform
national and international IT and NI conferences. nursing in the twenty-first century.
In 2014, a significant accomplishment by the his- This chapter highlights the historical dates of events
tory project committee was the creation of the Nursing as well as the major pioneer(s) involved which helps put
Informatics History Collection sponsored by the in perspective when and how the Information Technology
University of Texas School of Biomedical Informatics and/or Nursing Informatics were integrated into the nurs-
at Houston (SBMI) for the John P. McGovern Historical ing profession (Table 1-1). They were also categorized
Collections and Research Center at the Texas Medical and described in the chapter “Historical Perspectives of
Center Library. The collection is accessible to those inter- Nursing Informatics” (Saba & Westra, 2015) published in
ested in exploring the history of the pioneers. The collec- the sixth edition of Essentials of Nursing Informatics (Saba &
tion continues to grow through the generous donations McCormick, 2015). In this edition, the major landmark
from the pioneers in nursing informatics. The library milestones have been updated in Table 1-1. The mile-
accepts books, journals, and other publications but also stone events are listed in chronological order including
technological materials such as CDs, DVDs, as well as for the first time the key NI pioneer or expert involved in
microfiche, correspondence, professional meeting materi- the event as well as the first time the key event occurred
als, and any other invaluable material that represents the and which may be ongoing. Many other events may have
advancement of nursing and computers including IT. occurred but this table represents the most complete his-
tory of the NI specialty movement.
There are currently several key events in which the NI
SUMMARY community participates, and many of them are held annu-
ally. The conferences, symposia, institutes, and workshops
Computers, and subsequently IT, emerged during the past provide an opportunity for NI novices and experts to net-
five decades in the healthcare industry. Hospitals began work and share their experiences. They also provide the
to use computers as tools to update paper-based patient latest information, newest exhibits, and demonstrations
records. Computer systems in healthcare settings pro- on this changing field shown in Table 1-3.
vided the information management capabilities needed to
assess, document, process, and communicate patient care.
As a result, the “human–machine” interaction of nursing
and computers has become a new and lasting symbiotic
TABLE 1.3  Major Nursing Informatics Events and
relationship (Blum, 1990; Collen, 1994; Kemeny, 1972).
Conferences for Nursing Informaticians.
The history of informatics from the perspective of the
pioneers has been described in this chapter. The complete A. Conferences and Workshops
video, audio, and transcripts can be found on the AMIA
Web site (www.amia.org/niwg-history-page). Over the last •• American Medical Informatics Association (AMIA)
Annual Symposium:
50 years, nurses have used and contributed to the evolving ◦◦ Nursing Informatics Workshop
HIT or EHR systems for the improved practice of nurs- ◦◦ Nursing Informatics Working Group (NIWG)
ing. Innumerable organizations sprang up in an attempt ◦◦ Harriet Werley Award
to set standards for nursing practice and education, stan- ◦◦ Virginia K. Saba Award
dardize the terminologies, create standard structures for •• HIMSS Annual Conference and Exhibition
EHRs, and attempt to create uniformity for the electronic ◦◦ Nursing Informatics Symposium
exchange of information. This chapter highlighted a few ◦◦ Nursing Informatics Task Force
key organizations. ◦◦ Nursing Informatics Leadership Award
The last section focuses on landmark events in nurs- •• Summer Institute in Nursing Informatics (SINI) at
University of Maryland, Baltimore, MD. (Annual)
ing informatics, including major milestones in national
and international conferences, symposia, workshops, and •• Annual American Academy of Nursing (Annual)
◦◦ Panel of Nursing Informatics Experts
organizational initiatives contributing to the computer
literacy of nurses, as listed in Table 1-1. The success of
•• Sigma Theta Tau International: Bi-Annual Conference
◦◦ Virginia K. Saba Nursing Informatics Leadership
the conferences and the appearance of nursing articles, Award (Bi-Annual)
journals, books, and other literature on this topic demon- ◦◦ Technology Award; Information Resources (Annual)
strated the intense interest nurses had in learning more (Continued)
about computers and information technologies. These

ch01.indd 24 22-10-2020 03:11:54

 Chapter 1 • Historical Perspectives of Nursing Informatics 25

TABLE 1.3  Major Nursing Informatics Events and C. ANA approved the formation of the Council on
Conferences for Nursing Informaticians. Computer Applications in Nursing (CCAN).A
(Continued) Physiological Monitoring System emerged for
documenting nursing practice.All of the above
•• Nursing Informatics Special Interest Group of the 3. Which event was the most significant milestone for
International Medical Informatics Association (IMIA/
NI-SIG): Tri-Annual Conference
informatics in the 1990s?
◦◦ Starting 2014 Bi-Annual Conference A. Nursing presented first nursing papers at
•• International Medical Informatics Association (IMIA): SCAMC.
Triennial Congress
B. HITECH Act was passed.
◦◦ Nursing Sessions and Papers
•• Nursing Knowledge Big Data Science Initiative Annual C. ANA recognized the first four nursing
Conferences at University of Minnesota, Minneapolis, MN terminologies.
•• New England Nursing Informatics Annual Symposium F. NLN approved NI standards.
•• New England Nursing Informatics Consortium (NENIC)
H. All of the above.
B.   Professional Councils and/or Committees
4. Which event in 2000s became a significant milestone
•• American Nurses Association (ANA) for healthcare informatics?
◦◦ Nursing Informatics Database Steering Committee A. Bar coding technology emerged.
•• National League for Nursing (NLN) B. RFID technology emerged.
◦◦ Educational Technology and Information
Management Advisory Council (ETIMC) D. ONC was established
•• American Academy of Nursing (AAN) E. MU was initiated.
◦◦ Expert Panel of Nursing Informatics
•• American Medical Informatics Association F. All of the above.
◦◦ Nursing Informatics Working Group (NIWG) 5. Which is one of the most significant event(s) that
C. Credentialing/Certification/Fellowship emerged from the NI History Project.
A. Video-taping of ANPs.
•• American Nurses Association (ANA); American Nurses B. NLM’s NI Pioneers’ History Collection.
Credentialing Center (ANCC)
◦◦ Informatics Nursing Certification C. NLN’s Interactive NI Educational CDs.
•• HIMSS D. NI mentorship standards.
◦◦ Certified Professional in Healthcare Information and
Management Systems (CPHIMS) E. All of the above
6. What was learned from the NI Pioneers’
interviews?
A. A vision that NI could make nursing practice
TEST QUESTIONS
visible.
1. What was considered to be the first major clinical B. Learned NI primarily through hands-on
information system used for documenting nursing experiences.
practice in the 1970s? C. NI needed to be involved in the development of
A. Technicon Data System (TDS) healthcare systems.
B. Metathesaurus of the NLM D. NI was a new nursing specialty.
C. PLATOU.S. ANC Educational Workshop E. All of the above.
E. All of the above 7. What does the ANA Scope of NI Practice address?
2. Which event was the most significant milestone for A. Nursing Process
nursing and computers and/or nursing informatics B. Standards of Nursing Research, Administration,
in the 1980s? Education, and Practice
A. Internet emerged for public use. D. NI Educational Requirements
B. U.S. Army conducted an International Computer E. NI Terminologies
Conference in Europe.
F. All of the above

ch01.indd 25 22-10-2020 03:11:55

Discovering Diverse Content Through
Random Scribd Documents
[2010] Erskine and de Courteille both give Must̤ afa the commendation
the Turkī and Persian texts give to the carts.
[2011] According to Tod’s Rājastān, negotiations went on during the
interval, having for their object the fixing of a frontier between the
Rānā and Bābur. They were conducted by a “traitor” Ṣalaḥ’d-dīn Tūār
the chief of Raisin, who moreover is said to have deserted to Bābur
during the battle.
[2012] Cf. f. 89 for Bābur’s disastrous obedience to astrological
warning.
[2013] For the reading of this second line, given by the good MSS. viz.
Tauba ham bī maza nīst, bachash, Ilminsky (p. 405) has Tauba ham bī
maza, mast bakhis, which de Courteille [II, 276] renders by, “O
ivrogne insensé! que ne goûtes-tu aussi à la pénitence?” The Persian
couplet seems likely to be a quotation and may yet be found
elsewhere. It is not in the Rāmpūr Dīwān which contains the Turkī
verses following it (E. D. Ross p. 21).
[2014] kīchmāklīk, to pass over (to exceed?), to ford or go through a
river, whence to transgress. The same metaphor of crossing a stream
occurs, in connection with drinking, on f. 189b.
[2015] This line shews that Bābur’s renouncement was of wine only;
he continued to eat confections (ma‘jūn).
[2016] Cf. f. 186b. Bābur would announce his renunciation in Dīwān;
there too the forbidden vessels of precious metals would be broken.
His few words leave it to his readers to picture the memorable scene.
[2017] This night-guard (‘asas) cannot be the one concerning whom
Gul-badan records that he was the victim of a little joke made at his
expense by Bābur (H. N. Index s.n.). He seems likely to be the Ḥājī
Muḥ. ‘asas whom Abū’l-faẓl mentions in connection with Kāmrān in
953 ah. (1547 ad.). He may be the ‘asas who took charge of Bābur’s
tomb at Āgra (cf. Gul-badan’s H. N. s.n. Muḥ. ‘Alī ‘asas t̤ aghāī, and
Akbar-nāma trs. i, 502).
[2018] saqālī qīrqmāqta u qūīmāqta. Erskine here notes that “a vow
to leave the beard untrimmed was made sometimes by persons who
set out against the infidels. They did not trim the beard till they
returned victorious. Some vows of similar nature may be found in
Scripture”, e.g. II Samuel, cap. 19 v. 24.
[2019] Index s.n. The tamghā was not really abolished until Jahāngīr’s
time—if then (H. Beveridge). See Thomas’ Revenue Resources of the
Mughal Empire.
[2020] There is this to notice here:—Bābur’s narrative has made the
remission of the tamghā contingent on his success, but the farmān
which announced that remission is dated some three weeks before his
victory over Rānā Sangā (Jumāda II, 13th-March 16th). Manifestly
Bābur’s remission was absolute and made at the date given by Shaikh
Zain as that of the farmān. The farmān seems to have been
despatched as soon as it was ready, but may have been inserted in
Bābur’s narrative at a later date, together with the preceding
paragraph which I have asterisked.
[2021] “There is a lacuna in the Turkī copy” (i.e. the Elphinstone
Codex) “from this place to the beginning of the year 935. Till then I
therefore follow only Mr. Metcalfe’s and my own Persian copies”
(Erskine).
[2022] I am indebted to my husband for this revised version of the
farmān. He is indebted to M. de Courteille for help generally, and
specially for the references to the Qorān (q.v. infra).
[2023] The passages in italics are Arabic in the original, and where
traced to the Qorān, are in Sale’s words.
[2024] Qorān, Sūrah XII, v. 53.
[2025] Sūrah LVII, v. 21.
[2026] Sūrah LVII, v. 15.
[2027] Sūrah VII, v. 140.
[2028] Sūrah II, v. 185.
[2029] These may be self-conquests as has been understood by
Erskine (p. 356) and de Courteille (ii. 281) but as the Divine
“acceptance” would seem to Bābur vouched for by his military
success, “victories” may stand for his success at Kanwā.
[2030] Sūrah II, 177 where, in Sale’s translation, the change referred
to is the special one of altering a legacy.
[2031] The words dīgūchī and yīgūchī are translated in the second
Wāqi‘āt-i-bāburī by sukhan-gūī and [wīlāyat]-khwār. This ignores in
them the future element supplied by their component gū which would
allow them to apply to conditions dependent on Bābur’s success. The
Ḥai. MS. and Ilminsky read tīgūchī, supporter- or helper-to-be, in
place of the yīgūchī, eater-to-be I have inferred from the khwār of the
Pers. translation; hence de Courteille writes “amīrs auxquels incombait
l’obligation de raffermir le gouvernement”. But Erskine, using the Pers.
text alone, and thus having khwār before him, translates by, “amīrs
who enjoyed the wealth of kingdoms.” The two Turkī words make a
depreciatory “jingle”, but the first one, dīgūchī, may imply serious
reference to the duty, declared by Muḥammad to be incumbent upon
a wazīr, of reminding his sovereign “when he forgetteth his duty”.
Both may be taken as alluding to dignities to be attained by success in
the encounter from which wazīrs and amīrs were shrinking.
[2032] Firdausī’s Shāh-nāma [Erskine].
[2033] Also Chand-wāl; it is 25 m. east of Āgra and on the Jamna
[T̤ abaqāṭ-i-nāṣirī, Raverty, p. 742 n.9]
[2034] Probably, Overthrower of the rhinoceros, but if Gurg-andāz be
read, of the wolf.
[2035] According to the Persian calendar this is the day the Sun
enters Aries.
[2036] The practical purpose of this order of march is shewn in the
account of the battle of Pānīpat, and in the Letter of Victory, f. 319.
[2037] kurohcha, perhaps a short kuroh, but I have not found Bābur
using cha as a diminutive in such a case as kurohcha.
[2038] or Kānūa, in the Bīānā district and three marches from Bīāna-
town. “It had been determined on by Rānā Sangrām Sīngh (i.e.
Sangā) for the northern limit of his dominions, and he had here built a
small palace.” Tod thus describes Bābur’s foe, “Sangā Rānā was of the
middle stature, and of great muscular strength, fair in complexion,
with unusually large eyes which appear to be peculiar to his
descendants. He exhibited at his death but the fragments of a
warrior: one eye was lost in the broil with his brother, an arm in action
with the Lodī kings of Dehlī, and he was a cripple owing to a limb
being broken by a cannon-ball in another; while he counted 80
wounds from the sword or the lance on various parts of his body”
(Tod’s Rājastān, cap. Annals of Mewār).
[2039] Here M. de C. has the following note (ii, 273 n.); it
supplements my own of f. 264 [n. 3]. “Le mot arāba, que j’ai traduit
par chariot est pris par M. Leyden” (this should be Erskine) “dans le
sens de ‘gun', ce que je ne crois pas exact; tout au plus signifierait-il
affût” (gun-carriage). “Il me parait impossible d’admettre que Bāber
eût à sa disposition une artillerie attelée aussi considérable. Ces arāba
pouvaient servir en partie à transporter des pièces de campagne, mais
ils avaient aussi une autre destination, comme on le voit par la suite
du récit.” It does not appear to me that Erskine translates the word
arāba by the word gun, but that the arābas (all of which he took to be
gun-carriages) being there, he supposed the guns. This was not
correct as the various passages about carts as defences show (cf.
Index s.nn. arāba and carts).
[2040] It is characteristic of Bābur that he reproduces Shaikh Zain’s
Fatḥ-nāma, not because of its eloquence but because of its useful
details. Erskine and de Courteille have the following notes concerning
Shaikh Zain’s farmān:—“Nothing can form a more striking contrast to
the simple, manly and intelligent style of Baber himself, than the
pompous, laboured periods of his secretary. Yet I have never read this
Firmān to any native of India who did not bestow unlimited
admiration on the official bombast of Zeineddin, while I have met with
none but turks who paid due praise to the calm simplicity of Baber”
[Mems. p. 359]. “Comme la précédente (farmān), cette pièce est
rédigée en langue persane et offre un modèle des plus accomplis du
style en usage dans les chancelleries orientales. La traduction d’un
semblable morceau d'éloquence est de la plus grande difficulté, si on
veut être clair, tout en restant fidèle à l’original.”
Like the Renunciation farmān, the Letter-of-victory with its preceding
sentence which I have asterisked, was probably inserted into Bābur’s
narrative somewhat later than the battle of Kānwa. Hence Bābur’s
pluperfect-tense “had indited”. I am indebted to my husband for help
in revising the difficult Fatḥ-nāma; he has done it with consideration
of the variants between the earlier English and the French
translations. No doubt it could be dealt with more searchingly still by
one well-versed in the Qorān and the Traditions, and thus able to
explain others of its allusions. The italics denote Arabic passages in
the original; many of these are from the Qorān, and in tracing them
M. de Courteille’s notes have been most useful to us.
[2041] Qorān, cap. 80, last sentence.
[2042] Shaikh Zain, in his version of the Bābur-nāma, styles Bābur
Nawāb where there can be no doubt of the application of the title, viz.
in describing Shāh T̤ ahmāsp’s gifts to him (mentioned by Bābur on f.
305). He uses the title also in the farmān of renunciation (f. 313b),
but it does not appear in my text, “royal” (fortune) standing for it (in
loco p. 555, l. 10).
[2043] The possessive pronoun occurs several times in the Letter-of-
victory. As there is no semblance of putting forward that letter as
being Bābur’s, the pronoun seems to imply “on our side”.
[2044] The Bābur-nāma includes no other than Shaikh Zain’s about
Kanwā. Those here alluded to will be the announcements of success
at Milwat, Pānīpat, Dībālpūr and perhaps elsewhere in Hindūstān.
[2045] In Jūn-pūr (Āyīn-i-akbarī); Elliot & Dowson note (iv, 283-4)
that it appears to have included, near Sikandarpūr, the country on
both sides of the Gogra, and thence on that river’s left bank down to
the Ganges.
[2046] That the word Nawāb here refers to Bābur and not to his
lieutenants, is shewn by his mention (f. 278) of Sangā’s messages to
himself.
[2047] Qorān, cap. 2, v. 32. The passage quoted is part of a
description of Satan, hence mention of Satan in Shaikh Zain’s next
sentence.
[2048] The brahminical thread.
[2049] khār-i-miḥnat-i-irtidād dar dāman. This Erskine renders by
“who fixed thorns from the pangs of apostacy in the hem of their
garments” (p. 360). Several good MSS. have khār, thorn, but Ilminsky
has Ar. khimār, cymar, instead (p. 411). De Courteille renders the
passage by “portent au pan de leurs habits la marque douloureuse de
l’apostasie” (ii, 290). To read khimār, cymar (scarf), would serve, as a
scarf is part of some Hindū costumes.
[2050] Qorān, cap. 69, v. 35.
[2051] M. Defrémery, when reviewing the French translation of the
B.N. (Journal des Savans 1873), points out (p. 18) that it makes no
mention of the “blessed ten”. Erskine mentions them but without
explanation. They are the 'asharah mubash-sharah, the decade of
followers of Muḥammad who “received good tidings”, and whose
certain entry into Paradise he foretold.
[2052] Qorān, cap. 3, v. 20. M. Defrémery reads Shaikh Zain to mean
that these words of the Qorān were on the infidel standards, but it
would be simpler to read Shaikh Zain as meaning that the infidel
insignia on the standards “denounce punishment” on their users.
[2053] He seems to have been a Rājpūt convert to Muḥammadanism
who changed his Hindī name Silhādī for what Bābur writes. His son
married Sangā’s daughter; his fiefs were Raisin and Sārangpūr; he
deserted to Bābur in the battle of Kānwa. (Cf. Erskine’s History of
India i, 471 note; Mirāt-i-sikandarī, Bayley’s trs. s.n.; Akbar-nāma,
H.B.’s trs. i, 261; Tod’s Rājastān cap. Mewār.)
[2054] “Dejāl or al Masih al Dajjal, the false or lying Messiah, is the
Muhammadan Anti-christ. He is to be one-eyed, and marked on the
forehead with the letters K.F.R. signifying Kafer, or Infidel. He is to
appear in the latter days riding on an ass, and will be followed by
70,000 Jews of Ispahān, and will continue on the Earth 40 days, of
which one will be equal to a year, another to a month, another to a
week, and the rest will be common days. He is to lay waste all places,
but will not enter Mekka or Medina, which are to be guarded by
angels. He is finally to be slain at the gate of Lud by Jesus, for whom
the Musalmans profess great veneration, calling him the breath or
spirit of God.—See Sale’s Introductory Discourse to the Koran”
[Erskine].
[2055] Qorān, cap. 29, v. 5.
[2056] “This alludes to the defeat of [an Abyssinian Christian] Abraha
the prince of Yemen who [in the year of Muḥammad’s birth] marched
his army and some elephants to destroy the ka‘ba of Makka. ‘The
Meccans,’ says Sale, ‘at the appearance of so considerable a host,
retired to the neighbouring mountains, being unable to defend their
city or temple. But God himself undertook the defence of both. For
when Abraha drew near to Mecca, and would have entered it, the
elephant on which he rode, which was a very large one and named
Maḥmūd, refused to advance any nigher to the town, but knelt down
whenever they endeavoured to force him that way, though he would
rise and march briskly enough if they turned him towards any other
quarter; and while matters were in this posture, on a sudden a large
flock of birds, like swallows, came flying from the sea-coast, every-
one of which carried three stones, one in each foot and one in its bill;
and these stones they threw down upon the heads of Abraha’s men,
certainly killing every one they struck.’ The rest were swept away by a
flood or perished by a plague, Abraha alone reaching Senaa, where he
also died” [Erskine]. The above is taken from Sale’s note to the 105
chapter of the Qorān, entitled “the Elephant”.
[2057] Presumably black by reason of their dark large mass.
[2058] Presumably, devouring as fire.
[2059] This is 50 m. long and blocked the narrow pass of the Caspian
Iron-gates. It ends south of the Russian town of Dar-band, on the
west shore of the Caspian. Erskine states that it was erected to
repress the invasions of Yajuj and Mujuj (Gog and Magog).
[2060] Qorān, cap. lxi, v. 4.
[2061] Qorān, cap. ii, v. 4. Erskine appears to quote another verse.
[2062] Qorān, cap. xlviii, v. 1.
[2063] Index s.n.
[2064] Khirad, Intelligence or the first Intelligence, was supposed to
be the guardian of the empyreal heaven (Erskine).
[2065] Chīn-tīmūr Chīngīz-khānid Chaghatāī is called Bābur’s brother
because a (maternal-) cousin of Bābur’s own generation, their last
common ancestor being Yūnas Khān.
[2066] Sulaimān Tīmūrid Mīrān-shāhī is called Bābur’s son because his
father was of Bābur’s generation, their last common ancestor being Sl.
Abū-sa‘id Mīrzā. He was 13 years old and, through Shāh Begīm,
hereditary shāh of Badakhshān.
[2067] The Shaikh was able, it would appear, to see himself as others
saw him, since the above description of him is his own. It is confirmed
by Abū’l-faẓl and Badāyūnī’s accounts of his attainments.
[2068] The honourable post given to this amīr of Hind is likely to be
due to his loyalty to Bābur.
[2069] Aḥmad may be a nephew of Yūsuf of the same agnomen
(Index s.nn.).
[2070] I have not discovered the name of this old servant or the
meaning of his seeming-sobriquet, Hindū. As a qūchīn he will have
been a Mughūl or Turk. The circumstance of his service with a son of
Maḥmūd Mīrān-shāhī (down to 905 ah.) makes it possible that he
drew his name in his youth from the tract s.e. of Maḥmūd’s Ḥiṣār
territory which has been known as Little Hind (Index s.n. Hind). This
is however conjecture merely. Another suggestion is that as hindū can
mean black, it may stand for the common qarā of the Turks, e.g. Qarā
Barlās, Black Barlās.
[2071] I am uncertain whether Qarā-qūzī is the name of a place, or
the jesting sobriquet of more than one meaning it can be.
[2072] Soul-full, animated; var. Ḥai. MS. khān-dār. No agnomen is
used for Asad by Bābur. The Akbar-nāma varies to jāmadār,
wardrobe-keeper, cup-holder (Bib. Ind. ed. i, 107), and Firishta to sar-
jāmadar, head wardrobe-keeper (lith. ed. p. 209 top). It would be
surprising to find such an official sent as envoy to ‘Irāq, as Asad was
both before and after he fought at Kānwa.
[2073] son of Daulat Khān Yūsuf-khail Lūdī.
[2074] These are the titles of the 20th and 36th chapters of the
Qorān; Sale offers conjectural explanations of them. The “family” is
Muḥammad’s.
[2075] a Bāī-qarā Tīmūrid of Bābur’s generation, their last common
ancestor being Tīmūr himself.
[2076] an Aūzbeg who married a daughter of Sl. Ḥusain M. Bāī-qarā.
[2077] It has been pointed out to me that there is a Chinese title of
nobility Yūn-wāng, and that it may be behind the words jang-jang.
Though the suggestion appears to me improbable, looking to the
record of Bābur’s officer, to the prevalence of sobriquets amongst his
people, and to what would be the sporadic appearance of a Chinese
title or even class-name borne by a single man amongst them. I add
this suggestion to those of my note on the meaning of the words
(Index s.n. Muḥ. ‘Alī). The title Jūn-wāng occurs in Dr. Denison Ross’
Three MSS. from Kāshghar, p. 5, v. 5 and translator’s preface, p. 14.
[2078] Cf. f. 266 and f. 299. Yārāgī may be the name of his office,
(from yārāq) and mean provisioner of arms or food or other military
requirements.
[2079] or, Tardī yakka, the champion, Gr. monomachus (A. N. trs. i,
107 n.).
[2080] var. 1 watch and 2 g’harīs; the time will have been between 9
and 10 a.m.
[2081] jūldū ba nām al ‘azīz-i-barādar shud, a phrase not easy to
translate.
[2082] viz. those chained together as a defence and probably also
those conveying the culverins.
[2083] The comparison may be between the darkening smoke of the
fire-arms and the heresy darkening pagan hearts.
[2084] There appears to be a distinction of title between the akhta-
begī and the mīr-akhẉūr (master of the horse).
[2085] Qorān, cap. 14, v. 33.
[2086] These two men were in one of the flanking-parties.
[2087] This phrase “our brother” would support the view that Shaikh
Zain wrote as for Bābur, if there were not, on the other hand, mention
of Bābur as His Majesty, and the precious royal soul.
[2088] dīwānīān here may mean those associated with the wazīr in
his duties: and not those attending at Court.
[2089] Qorān, cap. 14, v. 52.
[2090] Index s.n. chuhra (a brave).
[2091] hizabrān-i-besha yakrangī, literally, forest-tigers (or, lions) of
one hue.
[2092] There may be reference here to the chains used to connect
the carts into a defence.
[2093] The braves of the khāṣa tābīn were part of Bābur’s own
centre.
[2094] perhaps the cataphract elephants; perhaps the men in mail.
[2095] Qorān, cap. 101, v. 54.
[2096] Qorān, cap. 101, v. 4.
[2097] bā andākhtan-i-sang u ẓarb-zan tufak bisyārī. As Bābur does
not in any place mention metal missiles, it seems safest to translate
sang by its plain meaning of stone.
[2098] Also, metaphorically, swords.
[2099] tīr. My husband thinks there is a play upon the two meanings
of this word, arrow and the planet Mercury; so too in the next
sentence, that there may be allusion in the kuākib s̤ awābit to the
constellation Pegasus, opposed to Bābur’s squadrons of horse.
[2100] The Fish mentioned in this verse is the one pictured by
Muḥammadan cosmogony as supporting the Earth. The violence of
the fray is illustrated by supposing that of Earth’s seven climes one
rose to Heaven in dust, thus giving Heaven eight. The verse is from
Firdausī’s Shāh-nāma, [Turner-Macan’s ed. i, 222]. The translation of
it is Warner’s, [ii, 15 and n.]. I am indebted for the information given
in this note to my husband’s long search in the Shāh-nāmā.
[2101] Qorān, cap. 3, v. 133.
[2102] Qorān, cap. 61, v. 13.
[2103] Qorān, cap. 48, v. 1.
[2104] Qorān, cap. 48, v. 3.
[2105] [see p. 572] farāsh. De Courteille, reading firāsh, translates
this metaphor by comme un lit lorsqu’il est défait. He refers to Qorān,
cap. 101, v. 3. A better metaphor for the breaking up of an army than
that of moths scattering, one allowed by the word farāsh, but possibly
not by Muḥammad, is vanished like bubbles on wine.
[2106] Bāgar is an old name for Dungarpūr and Bānswāra [G. of I. vi,
408 s.n. Bānṣwāra].
[2107] sic, Ḥai. MS. and may be so read in I.O. 217 f. 220b; Erskine
writes Bikersi (p. 367) and notes the variant Nagersi; Ilminsky (p.
421) N:krsī; de Courteille (ii. 307) Niguersi.
[2108] Cf. f. 318b, and note, where it is seen that the stones which
killed the lords of the Elephants were so small as to be carried in the
bill of a bird like a swallow. Were such stones used in matchlocks in
Bābur’s day?
[2109] guzāran, var. gurazān, caused to flee and hogs (Erskine notes
the double-meaning).
[2110] This passage, entered in some MSS. as if verse, is made up of
Qorān, cap. 17, v. 49, cap. 33, v. 38, and cap. 3, v. 122.
[2111] As the day of battle was Jumāda II. 13th (March 16th), the
Fatḥ-nāma was ready and dated twelve days after that battle. It was
started for Kābul on Rajab 9th (April 11th). Something may be said
here appropriately about the surmise contained in Dr. Ilminsky’s
Preface and M. de Courteille’s note to Mémoires ii, 443 and 450, to
the effect that Bābur wrote a plain account of the battle of Kanwā and
for this in his narrative substituted Shaikh Zain’s Fatḥ-nāma, and that
the plain account has been preserved in Kehr’s Bābur-nāma volume
[whence Ilminsky reproduced it, it was translated by M. de Courteille
and became known as a “Fragment” of Bāburiana]. Almost certainly
both scholars would have judged adversely of their suggestion by the
light of to-day’s easier research. The following considerations making
against its value, may be set down:—
(1) There is no sign that Bābur ever wrote a plain account of the
battle or any account of it. There is against his doing so his statement
that he inserts Shaikh Zain’s Fatḥ-nāma because it gives particulars. If
he had written any account, it would be found preceding the Fatḥ-
nāma, as his account of his renunciation of wine precedes Shaikh
Zain’s Farmān announcing the act.
(2) Moreover, the “Fragment” cannot be described as a plain account
such as would harmonize with Bābur’s style; it is in truth highly
rhetorical, though less so as Shaikh Zain’s.
(3) The “Fragment” begins with a quotation from the Bābur-nāma
(f.310b and n.), skips a good deal of Bābur’s matter preliminary to the
battle, and passes on with what there can be no doubt is a translation
in inferior Turkī of the Akbar-nāma account.
(4) The whole of the extra matter is seen to be continuous and not
fragmentary, if it is collated with the chapter in which Abū’l-faẓl
describes the battle, its sequel of events, the death, character,
attainments, and Court of Bābur. Down to the death, it is changed to
the first person so as to make Bābur seem to write it. The probable
concocter of it is Jahāngīr.
(5) If the Fragment were Bābur’s composition, where was it when
‘Abdu-r-raḥīm translated the Bābur-nāma in 998 ah.-1590 ad.; where
too did Abū’l-faẓl find it to reproduce in the Akbar-nāma?
(6) The source of Abū’l-faẓl’s information seems without doubt to be
Bābur’s own narrative and Shaikh Zain’s Fatḥ-nāma. There are many
significant resemblances between the two rhetoricians’ metaphors and
details selected.
(7) A good deal might be said of the dissimilarities between Bābur’s
diction and that of the “Fragment”. But this is needless in face of the
larger and more circumstantial objections already mentioned.
(For a fuller account of the “Fragment” see JRAS. Jan. 1906 pp. 81,
85 and 1908 p. 75 ff.)
[2112] T̤ ughrā means an imperial signature also, but would Bābur sign
Shaikh Zain’s Fatḥ-i-nāma? His autograph verse at the end of the
Rāmpūr Dīwān has his signature following it. He is likely to have
signed this verse. Cf. App. Q. [Erskine notes that titles were written on
the back of despatches, an unlikely place for the quatrain, one
surmises.]
[2113] This is in the Rāmpūr dīwān (E.D.R. Plate 17). Dr. E. Denison
Ross points out (p. 17 n.) that in the 2nd line the Ḥai. Codex varies
from the Dīwān. The MS. is wrong; it contains many inaccuracies in
the latter part of the Hindūstān section, perhaps due to a change of
scribe.
[2114] These words by abjad yield 933. From Bābur’s use of the
pluperfect tense, I think it may be inferred that (my) Sections a and b
are an attachment to the Fatḥ-nāma, entered with it at a somewhat
later date.
[2115] My translation of this puzzling sentence is tentative only.
[2116] This statement shews that the Dībālpūr affair occurred in one
of the B.N. gaps, and in 930 ah. The words make 330 by abjad. It
may be noted here that on f. 312b and notes there are remarks
concerning whether Bābur’s remission of the tamghā was contingent
on his winning at Kānwa. If the remission had been delayed until his
victory was won, it would have found fitting mention with the other
sequels of victory chronicled above; as it is not with these sequels, it
may be accepted as an absolute remission, proclaimed before the
fight. The point was a little uncertain owing to the seemingly
somewhat deferred insertion in Bābur’s narrative of Shaikh Zain’s
Farmān.
[2117] dā’ira, presumably a defended circle. As the word aūrdū
[bracketed in the text] shows, Bābur used it both for his own and for
Sangā’s camps.
[2118] Hence the Rānā escaped. He died in this year, not without
suspicion of poison.
[2119] aīchīmnī khālī qīldīm, a seeming equivalent for English, “I
poured out my spleen.”
[2120] var. malūk as e.g. in I.O. 217 f.225b, and also elsewhere in the
Bābur-nāma.
[2121] On f. 315 the acts attributed to Ilīās Khān are said to have
been done by a “mannikin called Rustam Khān”. Neither name
appears elsewhere in the B.N.; the hero’s name seems a sarcasm on
the small man.
[2122] Bābur so-calls both Ḥasan and his followers, presumably
because they followed their race sympathies, as of Rājpūt origin, and
fought against co-religionists. Though Ḥasan’s subjects, Meos, were
nominally Muḥammadans, it appears that they practised some Hindu
customs. For an account of Mīwāt, see Gazetteer of Ulwur (Alwar,
Alūr) by Major P. W. Powlett.
[2123] Alwar being in Mīwāt, Bābur may mean that bodies were found
beyond that town in the main portion of the Mīwāt country which lies
north of Alwar towards Dihlī.
[2124] Major Powlett speaking (p. 9) of the revenue Mīwāt paid to
Bābur, quotes Thomas as saying that the coins stated in Bābur’s
Revenue Accounts, viz. 169,810,00 tankas were probably Sikandarī
tankas, or Rs. 8,490,50.
[2125] This word appears to have been restricted in its use to the
Khān-zādas of the ruling house in Mīwāt, and was not used for their
subjects, the Meos (Powlett l.c. Cap. I.). The uses of “Mīwātī” and
“Meo” suggest something analogous with those of “Chaghatāī” and
“Mughūl” in Bābur’s time. The resemblance includes mutual dislike
and distrust (Powlett l.c.).
[2126] qīlūrlār aīkān dūr. This presumptive past tense is frequently
used by the cautious Bābur. I quote it here and in a few places near-
following because it supports Shaw’s statement that in it the use of
aīkān (īkān) reduces the positive affirmation of the perfect to
presumption or rumour. With this statement all grammarians are not
agreed; it is fully supported by the Bābur-nāma.
[2127] Contrast here is suggested between Sult̤ āns of Dihlī & Hind; is
it between the greater Turks with whom Bābur classes himself
immediately below as a conqueror of Hind, and the Lūdī Sult̤ āns of
Dihlī?
[2128] The strength of the Tijāra hills towards Dihlī is historical
(Powlett l.c. p. 132).
[2129] This is one of the names of the principal river which flows
eastwards to the south of Alwar town; other names are Bārah and
Rūparel. Powlett notes that it appears in Thorn’s Map of the battle of
Laswarree (1803 ad.), which he reproduces on p. 146. But it is still
current in Gurgaon, with also a variant Mānas-le, man-killer (G. of
Gurgaon 1910 ad. ivA, p.6).
[2130] aūltūrūrlār aīkān dūr, the presumptive past tense.
[2131] f.308.
[2132] qīlghān aīkān dūr, the presumptive past tense.
[2133] Sult̤ ān ātīghā juldū būlūb; Pers. trs. Juldū ba nām-i Sult̤ ān
shud. The juldū guerdon seems to be apart from the fief and
allowance.
[2134] f. 315.
[2135] Bābur does not record this detail (f. 315).
[2136] f. 298b and f. 328b. Ja‘far is mentioned as Mahdī’s son by Gul-
badan and in the Ḥabību’s-siyar iii, 311, 312.
[2137] f. 388b.
[2138] The town of Fīrūzpūr is commonly known as Fīrūzpūr-jhirka
(Fīrūzpūr of the spring), from a small perennial stream which issues
from a number of fissures in the rocks bordering the road through a
pass in the Mīwāt hills which leads from the town viâ Tijāra to Rewārī
(G. of Gurgaon, p. 249). In Abū’l-faẓl’s day there was a Hindū shrine
of Mahadeo near the spring, which is still a place of annual
pilgrimage. The Kūtila lake is called Kotla-jhil in the G. of G. (p. 7). It
extends now 3 m. by 2-1/2 m. varying in size with the season; in
Abū’l-faẓl’s day it was 4 kos (8 m.) round. It lies partly in the district of
Nūh, partly in Gurgaon, where the two tracts join at the foot of the
Alwar hills.
[2139] This is the frequently mentioned size for reservoirs; the
measure here is probably the qārī, cir. a yard.
[2140] Bābur does not state it as a fact known to himself that the
Mānas-nī falls into the Kūtila lake; it did so formerly, but now does
not, tradition assigning a cause for the change (G. of G. p. 6). He uses
the hear-say tense, kīrār aīmīsh.
[2141] Kharī and Toda were in Akbar’s sarkār of Rantaṃbhor.
[2142] Bhosāwar is in Bhurtpūr, and Chausa (or Jūsa) may be the
Chausath of the Āyīn-i-akbarī, ii, 183.
[2143] As has been noted frequently, this phrase stands for artificial
water-courses.
[2144] Certainly Trans-Hindū-kush lands; presumably also those of
Trans-Indus, Kābul in chief.
[2145] aūstī; perhaps the reservoir was so built as to contain the
bubbling spring.
[2146] Chūn jā’ī khẉush karda ām.
[2147] f. 315.
[2148] var. Janwār (Jarrett). It is 25 m. east of Āgra on the Muttra-
Etāwa road (G. of I.).
[2149] kūcha-band, perhaps a barricade at the limit of a suburban
lane.
[2150] This has been mentioned already (f. 327).
[2151] f. 315.
[2152] i.e. those professedly held for Bābur.
[2153] Or, according to local pronunciation, Badāyūn.
[2154] This is the old name of Shāhābād in Rāmpūr (G. of I. xxii,
197). The A.-i-A. locates it in Saṃbal. Cf. E. and D.’s History of India,
iv, 384 n. and v. 215 n.
[2155] Perhaps the one in Sītapūr.
[2156] f. 305b.
[2157] As the Elphinstone Codex which is the treasure-house of
Humāyūn’s notes, has a long lacuna into which this episode falls, it is
not known if the culprit entered in his copy of the Bābur-nāma a
marginal excuse for his misconduct (cf. f. 252 and n.); such excuse
was likely to be that he knew he would be forgiven by his clement
father.
[2158] f. 305b.
[2159] Kāmrān would be in Qandahār. Erskine notes that the sum
sent to him would be about £750, but that if the coins were rūpīs, it
would be £30,000.
[2160] qit̤ a‘, for account of which form of poem see Blochmann’s
translations of Saifī’s and Jāmī’s Prosody, p. 86.
[2161] Rāmpūr Dīwān (E. D. Ross’ ed. p. 16 and Plate 14a). I am
uncertain as to the meaning of ll. 4 and 10. I am not sure that what in
most MSS. ends line 4, viz. aūl dam, should not be read as aūlūm,
death; this is allowed by Plate 14a where for space the word is
divided and may be aūlūm. To read aūlūm and that the deserters fled
from the death in Hind they were anxious about, has an answering
phrase in “we still are alive”. Ll. 9 and 10 perhaps mean that in the
things named all have done alike. [Ilminsky reads khāir nafsī for the
elsewhere ḥaz̤ z̤ -nafsī.]
[2162] These are 20 attitudes (rak‘ah) assumed in prayer during
Ramẓān after the Bed-time Prayer. The ablution (ghusl) is the bathing
of the whole body for ceremonial purification.
[2163] This Feast is the ‘Id-i-fit̤ ṛ, held at the breaking of the Ramẓān
Fast on the 1st of Shawwāl.
[2164] Erskine notes that this is the earliest mention of playing-cards
he can recall in oriental literature.
[2165] f. 339b.
[2166] The two varieties mentioned by Bābur seem to be Diospyrus
melanoxylon, the wood of which is called tindu abnūs in Hindūstānī,
and D. tomentosa, Hindi, tindu (Brandis s.nn.). Bārī is 19 m. west of
Dūlpūr.
[2167] mī‘ād, perhaps the time at which the Shaikh was to appear
before Bābur.
[2168] The Pers. trs. makes the more definite statement that what
had to be read was a Section of the Qoran (wird). This was done with
remedial aim for the illness.
[2169] As this statement needs comment, and as it is linked to
matters mentioned in the Rāmpūr Dīwān, it seems better to remit
remarks upon it to Appendix Q, Some matters concerning the Rāmpūr
Dīwān.
[2170] risāla. See Appendix Q.
[2171] Elph. MS. lacuna; I.O. 215 lacuna and 217 f. 229; Mems. p.
373. This year’s narrative resumes the diary form.
[2172] There is some uncertainty about these names and also as to
which adversary crossed the river. The sentence which, I think,
shews, by its plural verb, that Humāyūn left two men and, by its co-
ordinate participles, that it was they crossed the river, is as follows:—
(Darwīsh and Yūsuf, understood) Qut̤ b Sīrwānī-nī u bīr pāra rājalār-nī
bīr daryā aūtūb aūrūshūb yakshī bāsīb tūrlār. Aūtūb, aūrūshūb and
bāsīb are grammatically referable to the same subject, [whatever was
the fact about the crossing].
[2173] bīr daryā; W.-i-B. 217 f. 229, yak daryā, one river, but many
MSS. har daryā, every river. If it did not seem pretty certain that the
rebels were not in the Miyān-dū-āb one would surmise the river to be
“one river” of the two enclosing the tract “between the waters”, and
that one to be the Ganges. It may be one near Saṃbhal, east of the
Ganges.
[2174] var. Shīrwānī. The place giving the cognomen may be Sarwān,
a thakurāt of the Mālwā Agency (G. of I.). Qut̤ b of Sīrwān may be the
Qut̤ b Khān of earlier mention without the cognomen.
[2175] n.w. of Aligarh (Kūl). It may be noted here, where instances
begin to be frequent, that my translation “we marched” is an evasion
of the Turkī impersonal “it was marched”. Most rarely does Bābur
write “we marched”, never, “I marched.”
[2176] in the Aligarh (Kūl) district; it is the Sikandara Rao of the A.-i-
A. and the G. of I.
[2177] Rāmpūr Dīwān (E. D. Ross’ ed., p. 19, Plate 16b). This Dīwān
contains other quatrains which, judging from their contents, may well
be those Bābur speaks of as also composed in Saṃbal. See Appendix
Q, Some matters concerning the Rāmpūr Dīwān.
[2178] These are aunts of Bābur, daughters of Sl. Abū-sa‘īd Mīrān-
shāhī.
[2179] Sikandarābād is in the Buland-shahr district of the United
Provinces.
[2180] It is not clear whether Bābur returned from Sīkrī on the day he
started for Jalīsīr; no question of distance would prevent him from
making the two journeys on the Monday.
[2181] As this was the rendezvous for the army, it would be
convenient if it lay between Āgra and Anwār; as it was 6 m. from
Āgra, the only mapped place having approximately the name Jalīsīr,
viz. Jalesar, in Etah, seems too far away.
[2182] Anwār would be suitably the Unwāra of the Indian Atlas, which
is on the first important southward dip of the Jumna below Āgra.
Chandwār is 25 m. east of Āgra, on the Muttra-Etāwah road (G. of I.);
Jarrett notes that Tiefenthaler identifies it with Fīrūzābād (A.-i-A. ii,
183 n.).
[2183] In the district of Kālpī. The name does not appear in maps I
have seen.
[2184] āghā, Anglicé, uncle. He was Sa‘īd Khān of Kāshghar. Ḥaidar
M. says Bābā Sl. was a spoiled child and died without mending his
ways.
[2185] From Kālpī Bābur will have taken the road to the s.w. near
which now runs the Cawnpur (Kānhpūr) branch of the Indian Midland
Railway, and he must have crossed the Betwa to reach Īrij (Irich,
Indian Atlas, Sheet 69 N.W.).
[2186] Leaving Īrij, Bābur will have recrossed the Betwa and have left
its valley to go west to Bāndīr (Bhander) on the Pahūj (Indian Atlas,
Sheet 69 S.W.).
[2187] beneficent, or Muḥassan, comely.
[2188] The one man of this name mentioned in the B.N. is an amīr of
Sl. Ḥusain Bāī-qarā.
[2189] It seems safe to take Kachwa [Kajwa] as the Kajwarra of Ibn
Batūta, and the Kadwāha (Kadwaia) of the Indian Atlas, Sheet 52 N.E.
and of Luard’s Gazetteer of Gwalior (i, 247), which is situated in 24°
58’ N. and 77° 57’ E. Each of the three names is of a place standing
on a lake; Ibn Batūta’s lake was a league (4 m.) long, Bābur’s about
11 miles round; Luard mentions no lake, but the Indian Atlas marks
one quite close to Kadwāha of such form as to seem to have a tongue
of land jutting into it from the north-west, and thus suiting Bābur’s
description of the site of Kachwa. Again,—Ibn Batūta writes of
Kajwarra as having, round its lake, idol-temples; Luard says of
Kadwāha that it has four idol-temples standing and nine in ruins;
there may be hinted something special about Bābur’s Kachwa by his
remark that he encouraged its people, and this speciality may be
interaction between Muḥammadanism and Hindūism serving here for
the purpose of identification. For Ibn Batūta writes of the people of
Kajwarra that they were jogīs, yellowed by asceticism, wearing their
hair long and matted, and having Muḥammadan followers who
desired to learn their (occult?) secrets. If the same interaction existed
in Bābur’s day, the Muḥammadan following of the Hindū ascetics may
well have been the special circumstance which led him to promise
protection to those Hindūs, even when he was out for Holy-war. It has
to be remembered of Chandīrī, the nearest powerful neighbour of
Kadwāha, that though Bābur’s capture makes a vivid picture of
Hindūism in it, it had been under Muḥammadan rulers down to a
relatively short time before his conquest. The jogīs of Kachwa could
point to long-standing relations of tolerance by the Chandīrī
Governors; this, with their Muḥammadan following, explains the
encouragement Bābur gave them, and helps to identify Kachwa with
Kajarra. It may be observed that Bābur was familiar with the
interaction of the two creeds, witness his “apostates”, mostly
Muḥammadans following Hindū customs, witness too, for the
persistent fact, the reports of District-officers under the British Rāj.
Again,—a further circumstance helping to identify Kajwarra, Kachwa
and Kadwāha is that these are names of the last important station the
traveller and the soldier, as well perhaps as the modern wayfarer,
stays in before reaching Chandīrī. The importance of Kajwarra is
shewn by Ibn Batūta, and of Kadwāha by its being a maḥāll in Akbar’s
sarkār of Bāyawān of the ṣūba of Āgra. Again,—Kadwāha is the place
nearest to Chandīrī about which Bābur’s difficulties as to intermediate
road and jungle would arise. That intermediate road takes off the
main one a little south of Kadwāha and runs through what looks like a
narrow valley and broken country down to Bhamor, Bhurānpūr and
Chandīrī. Again,—no bar to identification of the three names is placed
by their differences of form, in consideration of the vicissitudes they
have weathered in tongue, script, and transliteration. There is some
ground, I believe, for surmising that their common source is kajūr, the
date-fruit. [I am indebted to my husband for the help derived from
Ibn Batūta, traced by him in Sanguinetti’s trs. iv, 33, and S. Lee’s trs.
p. 162.]
(Two places similar in name to Kachwa, and situated on Bābur’s route
viz. Kocha near Jhansi, and Kuchoowa north of Kadwāha (Sheet 69
S.W.) are unsuitable for his “Kachwa”, the first because too near
Bandīr to suit his itinerary, the second because too far from the turn
off the main-road mentioned above, because it has no lake, and has
not the help in identification detailed above of Kadwāha.)
[2190] qūrūghīr which could mean also reserved (from the water?).
[2191] qāzān. There seems to have been one only; how few Bābur
had is shewn again on f. 337.
[2192] Indian Atlas, Sheet 52 N.E. near a tributary of the Betwa, the
Or, which appears to be Bābur’s Burhānpūr-water.
[2193] The bed of the Betwa opposite Chandīrī is 1050 ft. above the
sea; the walled-town (qūrghān) of Chandīrī is on a table-land 250 ft.
higher, and its citadel is 230 ft. higher again (Cunningham’s
Archeological Survey Report, 1871 A.D. ii, 404).
[2194] The plan of Chandīrī illustrating Cunningham’s Report (see last
note) allows surmise about the road taken by Bābur, surmise which
could become knowledge if the names of tanks he gives were still
known. The courtesy of the Government of India allows me to
reproduce that plan [Appendix R, Chandīrī and Gwālīāwar].
[2195] He is said to have been Governor of Chandīrī in 1513 ad.

[2196] Here and in similar passages the word m:ljār or m:lchār is

found in MSS. where the meaning is that of T. būljār. It is not in any
dictionary I have seen; Mr. Irvine found it “obscure” and surmised it to
mean “approach by trenches”, but this does not suit its uses in the
Bābur-nāma of a military post, and a rendezvous. This surmise,
containing, as it does, a notion of protection, links m:ljār in sense with
Ar. malja'. The word needs expert consideration, in order to decide
whether it is to be received into dictionaries, or to be rejected
because explicable as the outcome of unfamiliarity in Persian scribes
with T. būljār or, more Persico with narrowed vowels, bŭljăr. Shaw in
his Vocabulary enters būljāq (būljār?), “a station for troops, a
rendezvous, see malja',” thus indicating, it would seem, that he was
aware of difficulty about m:ljār and būljāq (būljār?). There appears no
doubt of the existence of a Turkī word būljār with the meanings Shaw
gives to būljāq; it could well be formed from the root būl, being,
whence follows, being in a place, posted. Maljā has the meaning of a
standing-place, as well as those of a refuge and an asylum; both
meanings seem combined in the m:ljār of f. 336b, where for
matchlockmen a m:ljār was ordered “raised”. (Cf. Irvine’s Army of the
Indian Moghuls p. 278.)
[2197] yāghdā; Pers. trs. sar-āshīb. Bābur’s remark seems to show
that for effect his mortar needed to be higher than its object.
Presumably it stood on the table-land north of the citadel.
[2198] shātū. It may be noted that this word, common in accounts of
Bābur’s sieges, may explain one our friend the late Mr. William Irvine
left undecided (l.c. p. 278), viz. shāt̤ ūr. On p. 281 he states that
nardubān is the name of a scaling-ladder and that Bābur mentions
scaling ladders more than once. Bābur mentions them however
always as shātū. Perhaps shāt̤ ūr which, as Mr. Irvine says, seems to
be made of the trunks of trees and to be a siege appliance, is really
shātū u ... (ladder and ...) as in the passage under note and on f.
216b, some other name of an appliance following.
[2199] The word here preceding tūra has puzzled scribes and
translators. I have seen the following variants in MSS.;—nūkrī or tūkrī,
b:krī or y:krī, būkrī or yūkrī, būkrāī or yūkrāī, in each of which the k
may stand for g. Various suggestions might be made as to what the
word is, but all involve reading the Persian enclitic ī (forming the
adjective) instead of Turkī līk. Two roots, tīg and yūg, afford plausible
explanations of the unknown word; appliances suiting the case and
able to bear names formed from one or other of these roots are
wheeled mantelet, and head-strike (P. sar-kob). That the word is
difficult is shewn not only by the variants I have quoted, but by
Erskine’s reading naukarī tūra, “to serve the tūras,” a requisite not
specified earlier by Bābur, and by de Courteille’s paraphrase, tout ce
qui est nécessaire aux touras.
[2200] Sl. Nāṣiru’d-dīn was the Khīljī ruler of Mālwā from 906 to 916
A.H. (1500-1510 ad.).
[2201] He was a Rājpūt who had been prime-minister of Sl. Maḥmūd
II. Khīljī (son of Nāṣīru’d-dīn) and had rebelled. Bābur (like some
other writers) spells his name Mindnī, perhaps as he heard it spoken.
[2202] Presumably the one in the United Provinces. For Shamsābād in
Gūālīār see Luard l.c. i, 286.
[2203] chīqtī; Pers. trs. bar āmad and, also in some MSS. namī bar
āmad; Mems. p. 376, “averse to conciliation”; Méms. ii, 329,
“s'élevèrent contre cette proposition.” So far I have not found Bābur
using the verb chīqmāq metaphorically. It is his frequent verb to
express “getting away”, “going out of a fort”. It would be a short step
in metaphor to understand here that Medinī’s men “got out of it”, i.e.
what Bābur offered. They may have left the fort also; if so, it would
be through dissent.
[2204] f. 332.
[2205] I.O. 217, f. 231, inserts here what seems a gloss, “Tā īn jā
Farsī farmūda” (gufta, said). As Bābur enters his speech in Persian, it
is manifest that he used Persian to conceal the bad news.
[2206] The Illustrated London News of July 10th, 1915 (on which day
this note is written), has an àpropos picture of an ancient fortress-
gun, with its stone-ammunition, taken by the Allies in a Dardanelles
fort.
[2207] The dū-tahī is the āb-duzd, water-thief, of f. 67. Its position
can be surmised from Cunningham’s Plan [Appendix R].
[2208] For Bābur’s use of hand (qūl) as a military term see f. 209.
[2209] His full designation would be Shāh Muḥammad yūz-begī.
[2210] This will be flight from the ramparts to other places in the fort.
[2211] Bābur’s account of the siege of Chandīrī is incomplete,
inasmuch as it says nothing of the general massacre of pagans he has
mentioned on f. 272. Khẉāfī Khān records the massacre, saying, that
after the fort was surrendered, as was done on condition of safety for
the garrison, from 3 to 4000 pagans were put to death by Bābur’s
troops on account of hostility shewn during the evacuation of the fort.
The time assigned to the massacre is previous to the jūhar of 1000
women and children and the self-slaughter of men in Medinī Rāo’s
house, in which he himself died. It is not easy to fit the two accounts
in; this might be done, however, by supposing that a folio of Bābur’s
MS. was lost, as others seem lost at the end of the narrative of this
year’s events (q.v.). The lost folio would tell of the surrender, one
clearly affecting the mass of Rājpūt followers and not the chiefs who
stood for victory or death and who may have made sacrifice to honour
after hearing of the surrender. Bābur’s narrative in this part certainly
reads less consecutive than is usual with him; something preceding
his account of the jūhar would improve it, and would serve another
purpose also, since mention of the surrender would fix a term ending
the now too short time of under one hour he assigns as the duration
of the fighting. If a surrender had been mentioned, it would be clear
that his “2 or 3 garīs” included the attacking and taking of the dū-tahī
and down to the retreat of the Rājpūts from the walls. On this Bābur’s
narrative of the unavailing sacrifice of the chiefs would follow in due
order. Khẉāfī Khān is more circumstantial than Firishta who says
nothing of surrender or massacre, but states that 6000 men were
killed fighting. Khẉāfī Khān’s authorities may throw light on the
matter, which so far does not hang well together in any narrative,
Bābur’s, Firishta’s, or Khẉāfī Khān’s. One would like to know what led
such a large body of Rājpūts to surrender so quickly; had they been
all through in favour of accepting terms? One wonders, again, why
from 3 to 4000 Rājpūts did not put up a better resistance to
massacre. Perhaps their assailants were Turks, stubborn fighters down
to 1915 ad.
[2212] For suggestion about the brevity of this period, see last note.
[2213] Clearly, without Bābur’s taking part in the fighting.
[2214] These words by abjad make 934. The Ḥai. MS. mistakenly
writes Būd Chandīrī in the first line of the quatrain instead of Būd
chandī. Khẉāfī Khān quotes the quatrain with slight variants.
[2215] Chandīrī t̤ aurī wilāyat (dā?) wāqī‘ būlūb tūr, which seems to
need dā, in, because the fort, and not the country, is described. Or
there may be an omission e.g. of a second sentence about the walled-
town (fort).
[2216] This is the “Kirat-sagar” of Cunningham’s Plan of Chandīrī; it is
mentioned under this name by Luard (l.c. i, 210). “Kirat” represents
Kirtī or Kirit Sīngh who ruled in Gūālīār from 1455 to 1479 ad., there
also making a tank (Luard, l.c. i, 232).
[2217] For illustrative photographs see Luard, l.c. vol. i, part iv.
[2218] I have taken this sentence to apply to the location of the
tanks, but with some doubt; they are on the table-land.
[2219] Bābur appears to have written Betwī, this form being in MSS. I
have read the name to be that of the river Betwa which is at a
considerable distance from the fort. But some writers dispraise its
waters where Bābur praises.
[2220] T. qīā means a slope or slant; here it may describe tilted
strata, such as would provide slabs for roofing and split easily for
building purposes. (See next note.)
[2221] ‘imārat qīlmāq munāsib. This has been read to mean that the
qīālar provide good sites (Mems. & Méms.), but position, distance
from the protection of the fort, and the merit of local stone for
building incline me to read the words quoted above as referring to the
convenient lie of the stone for building purposes. (See preceding
note.)
[2222] Chandīrī-dā judai (jady)-nīng irtiqā‘ī yīgīrma-bīsh darja dūr;
Erskine, p. 378, Chanderi is situated in the 25th degree of N. latitude;
de Courteille, ii, 334, La hauteur du Capricorne à Tchanderi est de 25
degrées. The latitude of Chandīrī, it may be noted, is 24° 43'. It does
not appear to me indisputable that what Bābur says here is a
statement of latitude. The word judai (or jady) means both Pole-star
and the Sign Capricorn. M. de Courteille translates the quoted
sentence as I have done, but with Capricorn for Pole-star. My
acquaintance with such expressions in French does not allow me to
know whether his words are a statement of latitude. It occurs to me
against this being so, that Bābur uses other words when he gives the
latitude of Samarkand (f. 44b); and also that he has shewn attention
to the Pole-star as a guide on a journey (f. 203, where he uses the
more common word Qut̤ b). Perhaps he notes its lower altitude when
he is far south, in the way he noted the first rise of Canopus to his
view (f. 125).
[2223] Mallū Khān was a noble of Mālwā, who became ruler of Mālwā
in 1532 or 1533 ad. [?], under the style of Qādir Shāh.
[2224] i.e. paid direct to the royal treasury.
[2225] This is the one concerning which bad news reached Bābur just
before Chandīrī was taken.
[2226] This presumably is the place offered to Medinī Rāo (f. 333b),
and Bikramājīt (f. 343).
[2227] Obviously for the bridge.
[2228] m:ljār (see f. 333 n.). Here the word would mean befittingly a
protected standing-place, a refuge, such as matchlockmen used (f.
217 and Index s.n. arāba).
[2229] sīghīrūrdī, a vowel-variant, perhaps, of sūghūrūrdī.
[2230] f. 331b. This passage shews that Bābur’s mortars were few.
[2231] nufūr qūl-lār-dīn ham karka bīla rah rawā kīshī u āt aītīlār, a
difficult sentence.
[2232] Afghānlār kūprūk bāghlāmāq-nī istib‘ād qīlīb tamaskhur qīlūrlār
aīkāndūr. The ridicule will have been at slow progress, not at the
bridge-making itself, since pontoon-bridges were common (Irvine’s
Army of the Indian Moghuls).
[2233] tūīlāb; Pers. trs. uftān u khezān, limping, or falling and rising,
a translation raising doubt, because such a mode of progression could
hardly have allowed escape from pursuers.
[2234] Anglicé, on Friday night.
[2235] According to the Persian calendar, New-year’s-day is that on
which the Sun enters Aries.
[2236] so-spelled in the Ḥai. MS.; by de Courteille Banguermādū; the
two forms may represent the same one of the Arabic script.
[2237] or Gūī, from the context clearly the Gumti. Jarrett gives Godi
as a name of the Gumti; Gūī and Godī may be the same word in the
Arabic script.
[2238] Some MSS. read that there was not much pain.
[2239] I take this to be the Kali-Sarda-Chauka affluent of the Gogra
and not its Sarju or Saru one. To so take it seems warranted by the
context; there could be no need for the fords on the Sarju to be
examined, and its position is not suitable.
[2240] Unfortunately no record of the hunting-expedition survives.
[2241] One historian, Aḥmad-i-yādgār states in his Tārīkh-i-salāt̤ īn-i-
afāghina that Bābur went to Lāhor immediately after his capture of
Chandīrī, and on his return journey to Āgra suppressed in the Panj-āb
a rising of the Mundāhar (or, Mandhar) Rājpūts. His date is discredited
by Bābur’s existing narrative of 934 ah. as also by the absence in 935
ah. of allusion to either episode. My husband who has considered the
matter, advises me that the Lāhor visit may have been made in 936 or
early in 937 ah. [These are a period of which the record is lost or, less
probably, was not written.]
[2242] Elph. MS. f. 262; I. O. 215 f. 207b and 217 f. 234b; Mems. p.
382. Here the Elphinstone MS. recommences after a lacuna extending
from Ḥai. MS. f. 312b.
[2243] See Appendix S:—Concerning the dating of 935 ah.

[2244] ‘Askarī was now about 12 years old. He was succeeded in

Multān by his elder brother Kāmrān, transferred from Qandahār
[Index; JRAS. 1908 p. 829 para. (1)]. This transfer, it is safe to say,
was due to Bābur’s resolve to keep Kābul in his own hands, a resolve
which his letters to Humāyūn (f. 348), to Kāmrān (f. 359), and to
Khwāja Kalān (f. 359) attest, as well as do the movements of his
family at this time. What would make the stronger government of
Kāmrān seem now more “for the good of Multān” than that of the
child ‘Askarī are the Bīlūchī incursions, mentioned somewhat later (f.
355b) as having then occurred more than once.
[2245] This will be his own house in the Garden-of-eight-paradises,
the Chār-bāgh begun in 932 ah. (August 1526 ad.).
[2246] To this name Khwānd-amīr adds Aḥmadu’l-ḥaqīrī, perhaps a
pen-name; he also quotes verses of Shihāb’s (Ḥabību’s-siyar lith. ed.
iii, 350).
[2247] Khwānd-amīr’s account of his going into Hindūstān is that he
left his “dear home” (Herāt) for Qandahār in mid-Shawwāl 933 ah.
(mid-July 1527 ad.); that on Jumāda I. 10th 934 ah. (Feb. 1st 1528
ad.) he set out from Qandahār on the hazardous journey into
Hindūstān; and that owing to the distance, heat, setting-in of the
Rains, and breadth of rapid rivers, he was seven months on the way.
He mentions no fellow-travellers, but he gives as the day of his arrival
in Āgra the one on which Bābur says he presented himself at Court.
(For an account of annoyances and misfortunes to which he was
subjected under Aūzbeg rule in Herāt see Journal des Savans, July
1843, pp. 389, 393, Quatremère’s art.)
[2248] Concerning Gūālīār see Cunningham’s Archeological Survey
Reports vol. ii; Louis Rousselet’s L’Inde des Rajas; Lepel Griffin’s
Famous Monuments of Central India, especially for its photographs;
Gazetteer of India; Luard’s Gazetteer of Gwalior, text and
photographs; Travels of Peter Mundy, Hakluyt Society ed. R. C.
Temple, ii, 61, especially for its picture of the fort and note (p. 62)
enumerating early writers on Gūālīār. Of Persian books there is Jalāl
Ḥiṣārī’s Tārīkh-i-Gwālīāwar (B.M. Add. 16,859) and Hirāman’s (B.M.
Add. 16,709) unacknowledged version of it, which is of the B.M. MSS.
the more legible.
[2249] Perhaps this stands for Gwālīāwar, the form seeming to be
used by Jalāl Ḥiṣārī, and having good traditional support (Cunningham
p. 373 and Luard p. 228).
[2250] tūshlānīb, i.e. they took rest and food together at mid-day.
[2251] This seems to be the conjoined Gambhīr and Bāngānga which
is crossed by the Āgra-Dhūlpūr road (G. of I. Atlas, Sheet 34).
[2252] aīchtūq, the plural of which shews that more than one partook
of the powders (safūf).
[2253] T. tālqān, Hindī sattu (Shaw). M. de Courteille’s variant
translation may be due to his reading for tālqān, tālghāq, flot,
agitation (his Dict. s.n.) and yīl, wind, for bīla, with.
[2254] in 933 ah. f. 330b.
[2255] “Each beaked promontory” (Lycidas). Our name “Selsey-bill” is
an English instance of Bābur’s (not infrequent) tūmshūq, beak, bill of
a bird.
[2256] No order about this Chār-bāgh is in existing annals of 934 ah.
Such order is likely to have been given after Bābur’s return from his
operations against the Afghāns, in his account of which the annals of
934 ah. break off.
[2257] The fort-hill at the northern end is 300 ft. high, at the southern
end, 274 ft.; its length from north to south is 1-3/4 m.; its breadth
varies from 600 ft. opposite the main entrance (Hātī-pūl) to 2,800 ft.
in the middle opposite the great temple (Sās-bhao). Cf. Cunningham
p. 330 and Appendix R, in loco, for his Plan of Gūālīār.
[2258] This Arabic plural may have been prompted by the greatness
and distinction of Mān-sing’s constructions. Cf. Index s.nn. begāt and
bāghāt.
[2259] A translation point concerning the (Arabic) word ‘imārat is that
the words “palace”, “palais”, and “residence” used for it respectively
by Erskine, de Courteille, and, previous to the Hindūstān Section, by
myself, are too limited in meaning to serve for Bābur’s uses of it in
Hindūstān; and this (1) because he uses it throughout his writings for
buildings under palatial rank (e.g. those of high and low in Chandīrī);
(2) because he uses it in Hindūstān for non-residential buildings (e.g.
for the Bādalgarh outwork, f. 341b, and a Hindū temple ib.); and (3)
because he uses it for the word “building” in the term building-stone,
f. 335b and f. 339b. Building is the comprehensive word under which
all his uses of it group. For labouring this point a truism pleads my
excuse, namely, that a man’s vocabulary being characteristic of
himself, for a translator to increase or diminish it is to intrude on his
personality, and this the more when an autobiography is concerned.
Hence my search here (as elsewhere) for an English grouping word is
part of an endeavour to restrict the vocabulary of my translation to
the limits of my author’s.
[2260] Jalāl Ḥiṣārī describes “Khwāja Raḥīm-dād” as a paternal-
nephew of Mahdī Khwāja. Neither man has been introduced by Bābur,
as it is his rule to introduce when he first mentions a person of
importance, by particulars of family, etc. Both men became disloyal in
935 ah. (1529 ad.) as will be found referred to by Bābur. Jalāl Ḥiṣārī
supplements Bābur’s brief account of their misconduct and Shaikh
Muḥammad Ghaus̤ ' mediation in 936 ah. For knowledge of his
contribution I am indebted to my husband’s perusal of the Tārīkh-i-
Gwālīāwar.
[2261] Erskine notes that Indians and Persians regard moonshine as
cold but this only faintly expresses the wide-spread fear of moon-
stroke expressed in the Psalm (121 v. 6), “The Sun shall not smite
thee by day, nor the Moon by night.”
[2262] Agarcha lūk balūk u bī sīyāq. Ilminsky [p. 441] has balūk balūk
but without textual warrant and perhaps following Erskine, as he says,
speaking generally, that he has done in case of need (Ilminsky’s
Preface). Both Erskine and de Courteille, working, it must be
remembered, without the help of detailed modern descriptions and
pictures, took the above words to say that the buildings were
scattered and without symmetry, but they are not scattered and
certainly Mān-sing’s has symmetry. I surmise that the words quoted
above do not refer to the buildings themselves but to the stones of
which they are made. T. lūk means heavy, and T. balūk [? block]
means a thing divided off, here a block of stone. Such blocks might be
bī sīyāq, i.e. irregular in size. To take the words in this way does not
contradict known circumstances, and is verbally correct.
[2263] The Rājas’ buildings Bābur could compare were Rāja Karna (or
Kirtī)’s [who ruled from 1454 to 1479 ad.], Rāja Mān-sing’s [1486 to
1516 ad.], and Rāja Bikramājīt’s [1516 to 1526 ad. when he was killed
at Panīpat].
[2264] The height of the eastern face is 100 ft. and of the western 60
ft. The total length from north to south of the outside wall is 300 ft.;
the breadth of the residence from east to west 160 ft. The 300 ft. of
length appears to be that of the residence and service-courtyard
(Cunningham p. 347 and Plate lxxxvii).
[2265] kaj bīla āqārītīb. There can be little doubt that a white
pediment would show up the coloured tiles of the upper part of the
palace-walls more than would pale red sandstone. These tiles were so
profuse as to name the building Chīt Mandīr (Painted Mandīr). Guided
by Bābur’s statement, Cunningham sought for and found plaster in
crevices of carved work; from which one surmises that the white
coating approved itself to successors of Mān-sing. [It may be noted
that the word Mandīr is in the same case for a translator as is ‘imārat
(f. 339b n.) since it requires a grouping word to cover its uses for
temple, palace, and less exalted buildings.]
[2266] The lower two storeys are not only backed by solid ground
but, except near the Hātī-pūl, have the rise of ground in front of them
which led Bābur to say they were “even in a pit” (chūqūr).
[2267] MSS. vary between har and bīr, every and one, in this
sentence. It may be right to read bīr, and apply it only to the eastern
façade as that on which there were most cupolas. There are fewer on
the south side, which still stands (Luard’s photo. No. 37).
[2268] The ground rises steeply from this Gate to an inner one, called
Hawā-pūl from the rush of air (hawā) through it.
[2269] Cunningham says the riders were the Rāja and a driver.
Perhaps they were a mahout and his mate. The statue stood to the
left on exit (chīqīsh).
[2270] This window will have been close to the Gate where no mound
interferes with outlook.
[2271] Rooms opening on inner and open courts appear to form the
third story of the residence.
[2272] T. chūqūr, hollow, pit. This storey is dark and unventilated, a
condition due to small windows, absence of through draught, and the
adjacent mound. Cunningham comments on its disadvantages.
[2273] Agarcha Hindūstānī takalluflār qīlīb tūrlār walī bī hawālīk-rāq
yīrlār dūr. Perhaps amongst the pains taken were those demanded for
punkhas. I regret that Erskine’s translation of this passage, so
superior to my own in literary merit, does not suit the Turkī original.
He worked from the Persian translation, and not only so, but with a
less rigid rule of translation than binds me when working on Bābur’s
ipsissima verba (Mems. p. 384; Cunningham p. 349; Luard p. 226).
[2274] The words aūrtā dā make apt contrast between the outside
position of Mān-sing’s buildings which helped to form the fort-wall,
and Bikramājīt’s which were further in except perhaps one wall of his
courtyard (see Cunningham’s Plate lxxxiii).
[2275] Cunningham (p. 350) says this was originally a bāra-dūrī, a
twelve-doored open hall, and must have been light. His “originally”
points to the view that the hall had been altered before Bābur saw it
but as it was only about 10 years old at that time, it was in its first
form, presumably. Perhaps Bābur saw it in a bad light. The
dimensions Cunningham gives of it suggest that the high dome must
have been frequently ill-lighted.
[2276] The word tālār, having various applications, is not easy to
match with a single English word, nor can one be sure in all cases
what it means, a platform, a hall, or etc. To find an equivalent for its
diminutive tālār-ghina is still more difficult. Raḥīm-dād’s tālār-ette will
have stood on the flat centre of the dome, raised on four pillars or
perhaps with its roof only so-raised; one is sure there would be a roof
as protection against sun or moon. It may be noted that the dome is
not visible outside from below, but is hidden by the continuation
upwards of walls which form a mean-looking parallelogram of
masonry.
[2277] T. tūr yūl. Concerning this hidden road see Cunningham p. 350
and Plate lxxxvii.
[2278] bāghcha. The context shews that the garden was for flowers.
For Bābur’s distinctions between bāghcha, bāgh and baghāt, see
Index s.nn.
[2279] shaft-ālū i.e. the rosy colour of peach-flowers, perhaps lip-red
(Steingass). Bābur’s contrast seems to be between those red
oleanders of Hindūstān that are rosy-red, and the deep red ones he
found in Gūālīār.
[2280] kul, any large sheet of water, natural or artificial (Bābur). This
one will be the Sūraj-kund (Sun-tank).
[2281] This is the Telī Mandīr, or Telingana Mandīr (Luard). Cf.
Cunningham, p. 356 and Luard p. 227 for accounts of it; and G. of I.
s.n. Telīagarhi for Telī Rājas.
[2282] This is a large outwork reached from the Gate of the same
name. Bābur may have gone there specially to see the Gūjarī Mandīr
said by Cunningham to have been built by Mān-sing’s Gūjar wife
Mṛiga-nayāna (fawn-eyed). Cf. Cunningham p. 351 and, for other
work done by the same Queen, in the s. e. corner of the fort, p. 344;
Luard p. 226. In this place “construction” would serve to translate
‘imārat (f. 340 n.).
[2283] āb-duzd, a word conveying the notion of a stealthy taking of
the water. The walls at the mouth of Urwā were built by Altamsh for
the protection of its water for the fort. The date Bābur mentions (a
few lines further) is presumably that of their erection.
[2284] Cunningham, who gives 57 ft. as the height of this statue,
says Bābur estimated it at 20 gaz, or 40 ft., but this is not so. Bābur’s
word is not gaz a measure of 24 fingers-breadth, but qārī, the length
from the tip of the shoulder to the fingers-ends; it is about 33 inches,
not less, I understand. Thus stated in qārīs Bābur’s estimate of the
height comes very near Cunningham’s, being a good 55 ft. to 57 ft. (I
may note that I have usually translated qārī by “yard”, as the yard is
its nearest English equivalent. The Pers. trs. of the B. N. translates by
gaz, possibly a larger gaz than that of 24 fingers-breadth i.e. inches.)
[2285] The statues were not broken up by Bābur’s agents; they were
mutilated; their heads were restored with coloured plaster by the
Jains (Cunningham p. 365; Luard p. 228).
[2286] rozan [or, aūz:n] ... tafarruj qīlīb. Neither Cunningham nor
Luard mentions this window, perhaps because Erskine does not; nor is
this name of a Gate found. It might be that of the Dhonda-paur
(Cunningham, p. 339). The 1st Pers. trs. [I.O. 215 f. 210] omits the
word rozan (or, auz:n); the 2nd [I.O. 217 f. 236b] renders it by jā’ī,
place. Manifestly the Gate was opened by Bābur, but, presumably, not
precisely at the time of his visit. I am inclined to understand that
rozan ... tafarruj karda means enjoying the window formerly used by
Muḥammadan rulers. If aūz:n be the right reading, its sense is
obscure.
[2287] This will have occurred in the latter half of 934 ah. of which no
record is now known.
[2288] He is mentioned under the name Asūk Mal Rājpūt, as a
servant of Rānā Sangā by the Mirāt-i-sikandarī, lith. ed. p. 161. In
Bayley’s Translation p. 273 he is called Awāsūk, manifestly by clerical
error, the sentence being az jānib-i-au Asūk Mal Rājpūt dar ān (qila‘)
būda....
[2289] ātā-līk, aūghūl-līk, i.e. he spoke to the son as a father, to the
mother as a son.
[2290] The Mirāt-i-sikandarī (lith. ed. p. 234, Bayley’s trs. p. 372)
confirms Bābur’s statement that the precious things were at
Bikramājīt’s disposition. Perhaps they had been in his mother’s charge
during her husband’s life. They were given later to Bahādur Shāh of
Gujrāt.
Welcome to our website – the perfect destination for book lovers and
knowledge seekers. We believe that every book holds a new world,
offering opportunities for learning, discovery, and personal growth.
That’s why we are dedicated to bringing you a diverse collection of
books, ranging from classic literature and specialized publications to
self-development guides and children's books.

More than just a book-buying platform, we strive to be a bridge

connecting you with timeless cultural and intellectual values. With an
elegant, user-friendly interface and a smart search system, you can
quickly find the books that best suit your interests. Additionally,
our special promotions and home delivery services help you save time
and fully enjoy the joy of reading.

Join us on a journey of knowledge exploration, passion nurturing, and

personal growth every day!

ebookbell.com