PanelNursingII&&& eNursing&Summary&–where&global ... · Ursula Hübnera, Ulla-Mari Kinnunenb,...

Ursula Hübnera, Ulla-Mari Kinnunenb, Joyce Sensmeierd, Claudia Bartzc,

a Health Informatics Research Group, University of Applied Sciences Osnabrück, Germany b University of Eastern Finland, Kuopio, Finland

c International Council of Nurses, Geneva, Switzerland d IHE USA, HIMSS, Chicago, IL, USA

Panel Nursing II eNursing Summary – where global standardisa8on and

regional prac8ce meet

Panel Program Session Room 4 Friday 23th Aug 2013 10:30 -‐ 12:00

Huebner, Kinnunen, Sensmeier, Bartz | MEDINFO 2013 | 23/08/13 | Copenhagen

10:30 – 10:45 Hübner U – PhD Professor University Appl. Sciences Osnabrück Germany eNursing Summary and the nursing process

10:45 – 11:00 Kinnunen UM – MSc, RN University of Eastern Finland

eNursing Summary: advances in Finland 11:00 – 11: 15 Sensmeier J – MS, RN HIMSS Chicago USA / IHE US

Exchanging nursing data using the IHE pa<ent plan of care and eNursing Summary

11:15 – 11:30 Bartz C – PhD Professor University of Wisconsin-‐Milwaukee / ICN

A toolkit of standards and exper<se: ICNP, ISO/CEN 18104, ICN’s bank-‐of-‐experts

11:30 – 12:00 Discussion: A universal model and framework for

the eNursing Summary?

Proposi8on 1

The eNursing Summary is a centrepiece of eHealth in par<cular for chronic and elderly pa<ents. … because nursing ensures process coordina[on and con[nuity in the care of pa[ents across (and within) se^ngs … because nurses have the most frequent contact with pa[ents and thus know their immediate needs best.


Entlassbericht Pflege [6]

Finnish Na[onal Nursing Documenta[on Model [5]

HL7 v3 messages for pa[ent discharge[6]

eNursing Summary [8]

ePflegebericht / eNursing Summary [2]

eNursing Summaries world wide

Increasing complexity of care processes

Information gaps compromise the health of patients

Increasing importance of transfer documents

eNursing Summaries as part of multi-professional care

Source: flags: flagpedia.net; IHE: wiki.ihe.net


Proposi8on 2

The eNursing Summary is a transfer document across (and within) seQngs that requires a high level of standardisa<on (syntac<c, seman<c and process interoperability)

however such a standard has to be flexible enough to consider many different seQngs and different clinical special<es


eNursing Summary and the nursing process

Ursula Hübner, PhD

Health Informa[cs Research Group, Dept. of Business Management and Social Sciences, University of Applied Sciences Osnabrück Germany

So=ware[3]

Par8cipatory design

Development of a data set based on[1]

• exis[ng data sets and informa[on models, e.g. HL7 RIM, ISO 18104

• the nursing process

Consensus building on • regional, •  supra-‐regional, •  na[onal level

Formal Standardisa8on • Via German HL7 User Group • Development of an implementa8on Guide [2]

Development of the German HL7 CDA based eNursing Summary

Collection of information

Nursing diagnoses

Nursing goals Care planning

Nursing interventions

Evaluation

Under the auspices of the

source: Logo DPR: HL7: wiki.hl7.de


Structure and content eNursing Summary

Header

Body

Social Information Homecare-Status

Reference To Legal Documents

Medical Information*

* Must be signed by a physician.

Nursing Process Assessment / Scores

Nursing Diagnoses

Nursing Goals

Nursing Interventions

Nursing Outcomes

Medical diagnoses

Medication

Biographische Informationen

Advance directive

Health care proxy

Application Forms

Wohnumfeld

Hilfsmittel


Nursing Process

Assessment / Scores

Nursing Goals

Nursing Diagnoses

etiology

symptoms

resources

Nursing Interventions Outcome

Subject

Target

patient

others

Means

products

manufacturer


Evalua8on of the German HL7 CDA based eNursing Summary

Comparison of the German HL7 eNursing Summary with 114 paperbased transfer forms

Iden8fied number of users: •  76 hospitals •  321 nursing homes •  409 community nursing services

Total: 806 ins8tu8ons

Developed and used by.... h(xi) municipality 38

commercial vendors 25

hospitals 23

nursing homes 15

community nursing services 10

no informa[on 3


Evalua8on results (1)

The German HL7 eNursing Summary could cover all informa[on included in the paper based discharge forms! It is thus valid in terms of contents.

15%$

23%$

44%$

45%$

75%$

92%$

Resources$

E2ology$

associated$means$

associated$interven2ons$

symptoms$

nursing$problems$

Nursing(diagnoses:(related(informa2on((n=114)(

The paper based discharge forms could transmit only a small por[on of the content of the German HL7 eNursing Summary.


Evalua8on results (2)

Most of the discharge forms were problem oriented!

Nursing problem iden[fied 92%

Scores used 39%

Nursing goals iden[fied 17%

Interven[ons iden[fied 62%

0%#0%# 7%#

16%#

77%#

Structure:(nursing(process((n=114)(

nursing#process#oriented#

goal#oriented#

problem#oriented#with#nursing#interven:ons#

interven:on#oriented#

problem#oriented#

5%#

15%#

37%#

43%#

Structure:(AEDLs((n=114)(

all#AEDLS#

no#AEDLs#

max#49%#of#AEDLs#

more#than#50%#of#AEDLS#


Current work (1)


ePA-‐Pflege-‐C lient mit GUI

Dateisystem

Eingabe der Pflegedaten /HL7-‐CDA-‐Rendering

Dateisystem

EPA-‐LE-‐C lientmit GUI

EPA-‐Kommunikations-‐

komponente

EPA-‐Kernsystem

Freigabe für EPA-‐Zustellung(Autorisierung kann auch zu

Beginn der Behandlung erfolgt sein)

eGK Autorisierungs-‐richtlinie

eGK

EPA-‐LE-‐C lientmit GUI

ePflege-‐bericht

IIAktenanlage [+ Ad-‐hoc-‐Autorisierung]

I

II

ArbeitsplatzumgebungCase Manager / Pflegekraft

IV

Export Versichertenstammdaten

Persönliche Versicherten-‐daten (XML)

https://ehealth-‐g1.fokus.fraunhofer.de/epa

Open eCard Plugin

IV

I

EPA-‐Kommunikation [+ Ad-‐hoc-‐Autorisierung]III Pflegeberichtserstellung

III

Current work (2)


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Wunddokument

0..* assignedEntity

typeCode*: <= AUTfunctionCode: CD CWE [0..1] < D:ParticipationFunctioncontextControlCode*: [1..1] < D:ContextControltime: TS [1..1]

author0..1 assignedPerson

0..1 representedOrganization

classCode*: <= ASSIGNEDid: DSET<II> [0..*]addr: COLL<AD> [0..*]

AssignedEntity

classCode*: <= PSNdeterminerCode*: <= INSTANCEname: COLL<EN> [0..*]telecom: COLL<TEL> [0..*]birthTime: TS [0..1]

Person

Organization

0..* associatedEntity

typeCode*: <= PARTfunctionCode: CD CWE [0..1] < D:ParticipationFunctioncontextControlCode*: [1..1] < D:ContextControltime: IVL<TS> [0..1]

participant

0..1 player

0..1 scoper

classCode*: < _RoleClassAssociativeid: DSET<II> [0..*]code: CD CWE [0..1] < D:RoleCodeaddr: COLL<AD> [0..*]telecom: COLL<TEL> [0..*]

AssociatedEntity

Person

0..* structuredBody

typeCode*: <= COMPcontextConductionInd:

component

classCode*: <= DOCBODYmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCode

structuredBody

0..* section_Wundart

typeCode*: <= COMP contextConductionInd:

component1classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_Wundart 0..* oBS_Wundart

typeCode*: < D:ActRelationshipEntry contextConductionInd:

sourceOf classCode*: <= OBSmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCodevalue: ANY CWE [0..1] < D:ObservationValue

OBS_Wundart

0..1 patient

0..1 providerOrganization

classCode*: <= PATid: DSET<II> [1..*]addr: COLL<AD> [0..*]telecom: COLL<TEL> [0..*]

PatientRole

classCode*: <= PSNdeterminerCode*: <= INSTANCEid: DSET<II> [0..*]name: COLL<EN> [0..*]administrativeGenderCode: CD CWE [0..1] < D:AdministrativeGenderbirthTime: TS [0..1]

Patient

Organization

1..* patientRole

typeCode*: <= RCTcontextControlCode*: [1..1] < D:ContextControl

recordTarget

0..1 assignedEntity

typeCode*: <= LAcontextControlCode*: [1..1] < D:ContextControltime: TS [1..1]signatureCode: CD CWE [0..1] < D:ParticipationSignature

legalAuthenticator

0..1 assignedPerson

0..1 representedOrganization

classCode*: <= ASSIGNEDid: DSET<II> [0..*]code: CD CWE [0..1] < D:RoleCodeaddr: COLL<AD> [0..*]telecom: COLL<TEL> [0..*]

AssignedEntity

classCode*: <= ORGdeterminerCode*: <= INSTANCEid: DSET<II> [0..*]name: COLL<EN> [0..*]telecom: COLL<TEL> [0..*]addr: COLL<AD> [0..*]

Organization

1..* intendedRecipient

typeCode*: <= IRCPcontextControlCode*: [1..1] < D:ContextControl

informationRecipient

0..1 player

0..1 scoper

classCode*: < V:x_InformationRecipientRoleid: DSET<II> [0..*]addr: COLL<AD> [0..*]telecom: COLL<TEL> [0..*]

IntendedRecipient

Organization

0..* section_BisherigeDiagnostik


component classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_BisherigeDiagnostik

0..* section_Lebensqualität


componentclassCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_Lebensqualität

0..* section_Wundheilungsstörung


component1classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_Wundheilungsstörung

0..* section_GesundheitsbezogenesSelbstmanagement


component1 classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_GesundheitsbezogenesSelbstmanagement

0..* section_LokalisationDerWunde


component classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_LokalisationDerWunde

0..* section_ZuletztDurchgeführteTherapien


componentclassCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Section_ZuletztDurchgeführteTherapien

0..* oBS_BisherigeDiagnostik

typeCode*: < D:ActRelationshipEntrycontextConductionInd:

sourceOfclassCode*: <= OBSmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCodevalue: ANY CWE [0..1] < D:ObservationValue

OBS_BisherigeDiagnostik

0..* oBS_Lebensqualität



OBS_Lebensqualität

0..* oBS_Wundheilungsstörung



OBS_Wundheilungsstörung

0..* oBS_LokalisierungDerWunde


sourceOfclassCode*: <= OBSmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCodevalue: ANY CWE [0..1] < D:ObservationValue

OBS_LokalisierungDerWunde

classCode*: <= SBADMmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCodeactionNegationInd:text: ED [0..1]statusCode: CS CNE [0..1] < D:ActStatuseffectiveTime: QSET<TS> [0..1]doseQuantity: PQ [0..1]rateQuantity: PQ [0..1]

SubstanceAdministration_ZuletztDurchgeführteTherapie

0..* observationMedia

typeCode*: <= REFR reference

classCode*: <= OBSmoodCode*: <= EVNid: DSET<II> [0..*]value: ANY CWE [0..1] < D:ObservationValue

ObservationMedia

0..* procedure_ZuletztDurchgeführteTherapie


sourceOfclassCode*: <= PROCmoodCode*: <= EVNid: DSET<II> [0..*]code: CD CWE [0..1] < D:ActCodeactionNegationInd:text: ED [0..1]statusCode: CS CNE [0..1] < D:ActStatuseffectiveTime: QSET<TS> [0..1]repeatNumber: IVL<INT.NONNEG> [0..1]methodCode: DSET<CD> CWE [0..*] < D:ProcedureMethod

Procedure_ZuletztDurchgeführteTherapie

classCode*: <= DOCSECTmoodCode*: <= EVNid: DSET<II> [0..*]code*: CD CWE [1..1] < D:ActCodetitle: ED [0..1]text: ED [0..1]

Wunde

1..1 wunde *


component

0..* substanceAdministration_ZuletztDurchgeführteTherapie


sourceOf1

Organization

Person

Person

Development of a HL7 CDA eWound Summary to supplement the eNursing Summary and other clinical documents

References (1)  Flemming D, Giehoff C, Hübner U. Entwicklung eines Standards für den elektronischen Pflegebericht auf der Basis der HL7

CDA Release 2, Pflegewissenschaft 2008;12:676-682.

(2)  Flemming D, Hübner U, Heitmann K, Oemig F, Thun S. Implementierungsleitfaden „ePflegebericht“ auf Basis der HL7 Clinical Document Architecture Release 2 für das deutsche Gesundheitswesen [Internet]. 2013 [cited 2013 Jan 30]. Available from: http://wiki.hl7.de/index.php/IG:Pflegebericht.

(3)  Giehoff C, Hübner U. Der elektronische Pflegebericht des „Netzwerks Versorgungskontinuität in der Region Osnabrück“ – Evaluationsergebnisse und ihre Konsequenzen, Pflegewissenschaft. 2006;06:371-377.

(4)  Goossen W. Sending electronic nursing discharge messages using the HL7 v3 Care Provision standard. Stud Health Technol Inform. 2009;146:269–75.

(5)  Häyrinen K, Lammintakanen J, Saranto K. Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. Int J Med Inform. Aug 2010;79(8):554–64.

(6)  HL7 Anwendergruppe Österreich (HL7 Austria). HL7 Implementation guide for CDA R2: Entlassungsbrief Pflege 2012. 2012 [cited 2012 Dec 31]. Available from: http://www.elga.gv.at/index.php?id=28.

(7)  Hübner U, Flemming D, Heitmann KU, Oemig F, Thun S, Dickerson A, Veenstra M. The Need for Standardised Documents in Continuity of Care: Results of Standardising the eNursing Summary. Stud Health Technol Inform. 2010;160:1169-73.

(8)  IHE Patient Care Coordination Nursing Subcommitee (IHE PCC). Implementation Priorities for the Integrating the Healthcare Enterprise (IHE) Nursing Subcommitee. White Paper to Advocate the Uptake of Patient Plan of Care and eNursing Summary Profiles 2012. 2012 [cited 2012 Dec 31]. Available from: http://www.ihe.net.


eNursing Summary: advances in Finland

Ulla-Mari Kinnunen, MHSc, RN, PhD-‐student Kaija Saranto, PhD, professor

University of Eastern Finland, Department of Health and Social Management, Finland

Finnish Na8onal Nursing Documenta8on Model

•  Is based on –  defined core nursing data (NMDS) –  nursing process model –  FinCC

•  Finnish Care Classifica[on (FinCC) –  Classifica[on of nursing diagnoses (FiCND) –  Classifica[on of nursing interven[ons (FiCNI) –  Classifica[on of nursing outcomes (FiCNO)


Na8onally defined core nursing data (NMDS)

•  Nursing diagnoses •  Nursing interven[ons •  Nursing outcomes •  Intensity •  Nursing summary

Form the structure of the Nursing Summary


NURSING DIAGNOSIS, SKIN INTEGRITY / Acute wounds / Traumatic wound

AIM / SKIN INTEGRITY

NURSING INTERVENTIONS, MEDICATION / Medication distribution / Local anaesthetic NURSING INTERVENTIONS, ADL / Care of cleanness / Wash support NURSING INTERVENTIONS, SKIN INTEGRITY / Wound care

NURSING INTERVENTIONS, SKIN INTEGRITY / Wound care / Wound dressing change

NURSING INTERVENTIONS, SENSORY / Pain monitoring / Pain assessment (quality, location, prevalens)

NURSING INTERVENTIONS, ACTIVITY / Activity guidance EVALUATION / NURSING OUTCOMES / SKIN INTEGRITY

Status S Stabilized


Nursing Diagnosis

Nursing Interventions

Nursing Outcomes

Patient Care Intensity

eNursing Summary

Nursing records

eNursing Summary

National Patient Record Archive

New care period

eNursing Summary

Minna Mykkänen 2011

eNursing summary today

•  Kuopio University Hopital: Structured nursing summary is made mostly to every pa[ent transferred from hospital to follow-‐up care -‐> eNursing summary (sent electronically) around 10-‐20 %

•  eNursing summary supplements/improves medical care summary

•  eNursing summary improves con[nuity of care

•  The feedback from the follow-‐up care is very posi[ve –  Clear and easy to read, includes comprehensive pa[ent informa[on

•  eNursing summary is transferred to na[onal eArchive


eNursing summary today

•  Aggrega[ng eNursing summaries is easy, but: –  Nursing documenta[on must be uniform and of good quality

–  It needs educa[on, prac[sing, technical skills with EPRs

–  EPR must support the func[onality of eNursing summary ( in and

between hospitals )

–  Nurses want more structured summaries (framework)

–  Medica[on lists should be included automa[cally into eNursing summaries


Thank You!

ulla-‐[email protected]

Exchanging nursing data using the IHE pa8ent plan of care and eNursing Summary

Joyce Sensmeier MS, RN-‐BC, CPHIMS, FHIMSS, FAAN

Vice President, Informa[cs, HIMSS President, IHE USA


What is IHE?

•  A common technical framework for harmonizing and implemen[ng mul[ple standards –  Applica[on-‐to-‐applica[on –  System-‐to-‐system –  Se^ng-‐to-‐se^ng

•  A path to seamless health informa[on movement within and between enterprises, regions, na[ons

•  A forum for unbiased selec[on and coordinated use of established health data and general IT standards to address specific clinical needs


IHE Process How does IHE work?


The value of interoperable nursing data

–  Plan for early interven[ons with appropriate resources based on pa[ent acuity including nurse staffing (resource maximiza[on)

–  Support the prac[ce of communica[ng and represen[ng pa[ent data so it is reusable

–  Complete clinical informa[on promotes safety and improved outcomes

–  Con[nuity of care delivery using a care plan

–  Promotes safe transfers of care for improved outcomes

What is IHE’s Value?


Value of Accurate Pa8ent Data

•  Decreased risk of error during transfer of care –  Data re-‐entry may increase chance of error –  Inefficient use of staffing and acuity tools

•  Improved quality of care, [mely delivery

•  Decreased costs by elimina[ng redundancy

•  Improved work flow with [mely, accessible clinical data

•  Allows for clinician collabora[on and early interven[on


IHE and Nursing

•  2006 IHE Nursing Special Interest Group formed –  Developed Func[onal Status Assessment Profile

•  2008 Nursing Subcommipee launched •  2009 Pa[ent Plan of Care Profile developed •  2010 Work began on e-‐Nursing Summary •  2011 Work began on Nursing Workflow


IHE Nursing Profiles

Goal: Move nursing data between care seQngs and across <me and space

Func*onal Status Assessment (FSA) Profile •  Move data from Long Term Care into Acute Care and back without regard

for vendor applica[on Pa*ent Plan of Care (PPOC) Profile •  Captures data related for crea[ng and managing individualized pa[ent care

between and among EHR systems e-‐Nursing Summary (eNS) •  Interoperable summary of nursing data that communicates pa[ent care

needs to another care provider Nursing Workflow •  Manages and tracks tasks related to pa[ent-‐centric workflows for health

professionals


Func8onal Status Assessment

Considera8ons •  Need to demonstrate value and feasibility

•  Scales chosen are evidence-‐based with strong reliability and validity

•  Widely accepted cross-‐enterprise or required/recommended by

accredi[ng agencies Content Scales •  Numeric Ra[ng Scale (NRS-‐11) for Pain

•  Braden Scale for Predic[ng Pressure Sore Risk©

•  Geriatric Depression Scale (GDS)

•  Minimum Data Set – Sec[on G


Pa8ent Plan of Care

e-‐Nursing Summary

•  Iden[fy key data elements –  Present in any nursing hand-‐off/transfer –  Necessary for pa[ent care

•  Develop crucial scenarios

–  Shis report –  Pa[ent transfer to OR –  Receiving a pa[ent from the ER –  Discharge a pa[ent to home care

•  “Marry” the key elements to the scenarios


Data Elements Selected

Ä Ac[vity Restric[ons Ä Medical Diagnosis Ä Allergies Ä Medica[ons Ä Fall Risk Ä Orders Ä Code Status Ä Oxygen Requirement Ä Complica[on Ä Precau[ons Ä Devices Ä Primary Language Spoken Ä Diet & Nutri[on Ä Procedure Ä  Intake and Output Ä Special Needs Ä Coded Results Ä Assessment of Mental Status, Pain, Vital Signs, Wound


Nursing Workflow

•  Scenario details of nursing ac[vi[es –  Clinical Assessment –  Administering medica[on –  Delivering nursing interven[ons for the pa[ent –  Educa[on of pa[ent and/or family –  Clinician communica[on

•  Sequence of details

–  Examples: •  What are the details of administering pain medica[on? •  Sending a pa[ent home or transferring to another area in the hospital

•  Preparing a pa[ent care plan


Key Points

•  Use of nursing cri[cal thinking processes and documenta[on requirements fit well into the IHE method

•  IHE provides a proven process for enabling interoperability between disparate systems

•  Collec[on of nursing data across [me and care se^ngs will allow research to determine evidence based prac[ce guidelines for the future


ICN Role in eNursing Summary Standardisation and Implementation

Claudia Bartz, PhD, RN, FAAN Amy Coenen, PhD, RN, FAAN

Presentation objectives •  Describe ICN eHealth Programme

vision and goals •  Discuss ICN role in advancing eNursing Summary

–  Synthesis of standards, existing applications, expert opinion

–  Work toward international framework

WHO eHealth definition

eHealth is the use of information and

communication technologies (ICT)

for health

ICN eHealth Programme •  Transforming nursing through the visionary

application of information and communication technology

•  Encompasses –  ICNP Programme –  ICN Telenursing Network –  Connecting Nurses (Sanofi) –  Professional collaborations

eHealth Programme Goals •  Support eHealth practice (technology)

•  Recognised as an authority on eHealth (professional)

•  Positioned centrally in the eHealth community (business)

Background

•  Hübner & colleagues proposed eNursing Summary (MedInfo2010)

•  International work considered –  Dickerson & Sensmeier (HIMSS - IHE) –  Saranto (Finland – FinCC) –  HL7 CDA

•  ICN approached at NI2012 for –  Nurse experts globally –  ICNP applications –  Work going forward

ICN Initial Survey

•  July 2013

•  Purpose: explore existing use and content of eNursing summaries

•  Goal: support work for eNursing Summary framework with –  Continuity of Care emphasis –  International consensus –  International EHR application

Survey Methods

•  Exploratory design; approved by IRB •  Convenience sample

•  ICN Accredited Centre Directors •  20 surveyed, 9 responded (45%)

•  Worldwide setting (7 countries) •  Web-based survey (SurveyMonkey®)

•  8 questions + comments section

Survey Findings 1

•  Use? •  Always 66.7% Sometimes 33.3%

•  Where?

•  Hospital (100%), Nursing Home & Ambulatory Care (55.6%) Home Care (33.3%)

•  Who? •  Physicians & Nurses (88.9%), also Social Workers,

Physiotherapists, Dentists

•  Nursing Content? •  Always (55.6%) Sometimes (44.4%)

Survey Findings 2

What type of nursing data in a summary?

–  Problems/ Nursing diagnoses –  Activities/ Nursing interventions –  Outcomes and Goals –  Means and Resources –  Nursing Care Plan –  Continuity of Care re: medication, wound

care, nutrition, social services

Survey Findings 3

How to improve the summary?

•  Integrate nursing throughout •  Integrate other disciplines’ data •  Use standard terminology and HIS •  Data available to providers and agencies •  Use ICNP; use minimum data set •  Ensure care continuity •  Simple, clear with targeted key outcomes

Issues to Consider

•  eNursing Summary standard –  structure –  Content

•  eNursing summary within multidisciplinary summary

•  Standard terminology

•  Implementation strategy

Recommendations 1

Survey larger sample for consensus on structure & content

–  ICN National Nurses Associations

–  ICN eHealth experts

–  IMIA-NI membership

Recommendations 2

•  Propose candidate data set for eNursing Summary –  based on work to date –  based on survey results –  reflecting related standards, eg ISO 18104,

EN ISO 13940

•  Validate and test in clinical settings

Conclusions

Integrate eNursing Summary in EHRs to

–  Assure continuity of care across all settings –  Assess conformance to quality standards –  Use data to build nursing knowledge and

evidence for practice

Huebner, Kinnunen, Sensmeier, Bartz | MEDINFO 2013 | 23/08/13 |

Copenhagen

Thank-you

[email protected]

[email protected]

Proposi8on 3

The eNursing Summary Framework is an abstrac<on of many proven and reliable real world documents and represents universal knowledge on the discharge and transfer process. … it thus should be based on a generic structure … it thus should be flexible with regard to use in different special[es and se^ngs … it thus should be comprehensive regarding the language (=coded terms)


Proposi8on 4

In order to make the vision of an eNursing Summary Framework viable necessary building blocks have to be iden<fied and assembled. These building blocks encompass … a procedure to reach consensus … a generic concept … a comprehensive terminology … a well defined implementa[on pathway … a concept to evaluate the technical implementa[on and the clinical outcome


PanelNursingII&&& eNursing&Summary&–where&global ... · Ursula Hübnera, Ulla-Mari Kinnunenb,...

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