Translation of Nursing Practice into the Electronic Healthcare Record Systems: Now & In Our Future
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Transcript of 1 the Electronic Health Record and Nursing-1
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The Electronic Health Record
(EHR) & Nursing
An International Agenda
Margaret Lunney, PhD, RN
Professor College of Staten Island, CUNY
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What is the EHR?
� Electronic patient/health record
� Multiple Linkages� Integrated� Universal
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History of the Patient Record
Paper records since 1800s
1918- Required Proliferation of paper records
±Millions in each institution
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Strengths of Paper Record
Familiar
Portable No downtime
Flexibility in recording data
Variety of ways to organize or seepatterns/trends of individual records
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Weaknesses Outweigh
theS
trengths
Content
Missing Excessive
Redundant
Illegible
Inaccurate
Lack of standardization
Incomprehensible
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Weaknesses of Paper Record
Format
Fragmented
Data cannot be found
Access & retrieval
Lack of access
Time to retrieve
Cost to enter data
Errors in data entry
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Weaknesses of Paper Record
� NOT integrated
Inpatient & outpatient
One type of service with others
Administrative, financial, quality indicators
Knowledge bases, e.g., guidelines
Other patients
Institutions & locations
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Weaknesses of Paper Record
Outpatient records
High number Scattered
Poorly organized
Inaccurate
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Goals of EHR
Totally integrated patient record systems
Linkages to resources & databases
Purposes1. Support patient care and improve quality
2. Enhance productivity and reduce costs
3. Support clinical and health services research
4. Accommodate future developments intechnology, policy, management and finance
5. Maintain patient confidentiality
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Why?
Data Information Knowledge
Graves & Corcoran, 1989
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How? Standardization
File names, Definitions, Descriptions
Unified languages in meta-thesaurus Mapping of languages with one another
Technological: Standards Associations International Standards Organization (ISO)
European Committee for Standardization (CEN)
American National Standards Institute (ANSI)
HL7 (see www.hl7.org)
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Advantages of EHR
Data abstracted, summarized,
aggregated; Local, regional, national,
international
Ease of entry, organization, & retrieval
Longitudinal records
Linkages to standards, guidelines, other
internet sources, recent research
Decision support systems
Other
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State of the Science in U.S.
DHHS--National Committee on Vital &
Health Statistics
Core Data Elements
National e Health Collaborative (NEHC)
� www.nationalehealth.org
� Purpose- Facilitate interoperability
Research
Being conducted by numerous agencies, e.g.,
AHRQ, NIH, NLM, VA, IOM, ANA, AHA, AMIA
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Standardization:
Nursing in the U.S
. NANDA (1973-present)
Nursing Minimum Data Set (1985)
Other classifications (1980¶s-present)
Omaha, Saba, Grobe, Ozbolt, NIC, NOC
ANA
1989, 1998: Committee on Nursing PracticeInformation Infrastructure
Unified Nursing Language System (UNLS),mapping of terms among nursing languages
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Standardization:
International Nursing
Countries involved worldwide, e.g.,
ACE
NDIO (E
uropean group), Japan, Korea,Australia, South American Countries, Africa
International Council of Nursing (ICN) International Classification of Nursing Practice
International Medical Informatics Assn.(IMIA); Working Group-Nursing Informatics
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Nursing Minimum Data Set
(NMDS
) : International Frame
Nursing Care Elements (4)
1. Nursing Diagnoses2. Nursing Interventions
3. Nursing-Sensitive Patient Outcomes
4. Intensity of Nursing Care
Patient Demographic Elements (5)
Service Elements (7)
12. Unique RN Provider Number
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SNLs: Ongoing
Development U.S.= systematic approval process (Coenen
et al, 2001, Computers in Nursing, 19, 240-246)
7 SNVs approved for EHR (met criteria) NANDA-International
Omaha System
Home Health Care Classification (Saba)
NIC NOC
Patient Care Data Set (Ozbolt)
Perioperative Dataset (AORN)
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The EHR, SNVs, & You
Use SNVs
Become familiar with computers
Provide feedback to SNL developers
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The EHR, SNVs, and YOU
Explain rationale to others
Create a spirit of support Discuss with nurse leaders
Teach others