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The Electronic Health Record (EHR) & Nursing. An International Agenda Margaret Lunney, PhD, RN Professor College of Staten Island, CUNY. What is the EHR?. Electronic patient/ health record Multiple Linkages Integrated Universal. History of the Patient Record.

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the electronic health record ehr nursing
The Electronic Health Record (EHR) & Nursing

An International Agenda

Margaret Lunney, PhD, RN

Professor

College of Staten Island, CUNY

what is the ehr
What is the EHR?
  • Electronic patient/

health record

  • Multiple Linkages
  • Integrated
  • Universal
history of the patient record
History of the Patient Record
  • Paper records since 1800s
  • 1918- Required
  • Proliferation of paper records
    • Millions in each institution
strengths of paper record
Strengths of Paper Record
  • Familiar
  • Portable
  • No downtime
  • Flexibility in recording data
  • Variety of ways to organize or see patterns/trends of individual records
weaknesses outweigh the strengths
Weaknesses Outweigh the Strengths
  • Content
    • Missing
    • Excessive
    • Redundant
    • Illegible
    • Inaccurate
    • Lack of standardization
    • Incomprehensible
weaknesses of paper record
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
weaknesses of paper record1
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
weaknesses of paper record2
Weaknesses of Paper Record
  • Outpatient records
    • High number
    • Scattered
    • Poorly organized
    • Inaccurate
goals of ehr
Goals of EHR
  • Totally integrated patient record systems
  • Linkages to resources & databases
  • Purposes

1. Support patient care and improve quality

2. Enhance productivity and reduce costs

3. Support clinical and health services research

4. Accommodate future developments in

technology, policy, management and finance

5. Maintain patient confidentiality

slide10
Why?
  • Data Information Knowledge

Graves & Corcoran, 1989

how standardization
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)
advantages of ehr
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
state of the science in u s
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
standardization nursing in the u s
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 Practice Information Infrastructure
    • Unified Nursing Language System (UNLS), mapping of terms among nursing languages
standardization international nursing
Standardization: International Nursing
  • Countries involved worldwide, e.g.,

ACENDIO (European 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
nursing minimum data set nmds international frame
Nursing Minimum Data Set (NMDS) : International Frame
  • Nursing Care Elements (4)

1. Nursing Diagnoses

2. Nursing Interventions

3. Nursing-Sensitive Patient Outcomes

4. Intensity of Nursing Care

  • Patient Demographic Elements (5)
  • Service Elements (7)

12. Unique RN Provider Number

snls ongoing development
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)
the ehr snvs you
The EHR, SNVs, & You
  • Use SNVs
  • Become familiar with computers
  • Provide feedback to SNL developers
the ehr snvs and you
The EHR, SNVs, and YOU
  • Explain rationale to others
  • Create a spirit of support
  • Discuss with nurse leaders
  • Teach others