Goossen William T F, Ozbolt Judy G, Coenen Amy, Park Hyeoun-Ae, Mead Charles, Ehnfors Margareta, Marin Heimar F
Acquest Research & Development, Koudekerk aan den Rijn, The Netherlands.
J Am Med Inform Assoc. 2004 May-Jun;11(3):186-94. doi: 10.1197/jamia.M1085. Epub 2004 Feb 5.
Since 1999, the Nursing Terminology Summits have promoted the development, evaluation, and use of reference terminology for nursing and its integration into comprehensive health care data standards. The use of such standards to represent nursing knowledge, terminology, processes, and information in electronic health records will enhance continuity of care, decision support, and the exchange of comparable patient information. As part of this activity, working groups at the 2001, 2002, and 2003 Summit Conferences examined how to represent nursing information in the Health Level 7 (HL7) Reference Information Model (RIM).
The working groups represented the nursing process as a dynamic sequence of phases, each containing information specific to the activities of the phase. They used Universal Modeling Language (UML) to represent this domain knowledge in models. An Activity Diagram was used to create a dynamic model of the nursing process. After creating a structural model of the information used at each stage of the nursing process, the working groups mapped that information to the HL7 RIM. They used a hierarchical structure for the organization of nursing knowledge as the basis for a hierarchical model for "Findings about the patient." The modeling and mapping reported here were exploratory and preliminary, not exhaustive or definitive. The intent was to evaluate the feasibility of representing some types of nursing information consistently with HL7 standards.
The working groups conducted a small-scale validation by testing examples of nursing terminology against the HL7 RIM class "Observation."
It was feasible to map patient information from the proposed models to the RIM class "Observation." Examples illustrate the models and the mapping of nursing terminology to the HL7 RIM.
It is possible to model and map nursing information into the comprehensive health care information model, the HL7 RIM. These models must evolve and undergo further validation by clinicians. The integration of nursing information, terminology, and processes in information models is a first step toward rendering nursing information machine-readable in electronic patient records and messages. An eventual practical result, after much more development, would be to create computable, structured information for nursing documentation.
自1999年以来，护理术语峰会推动了护理参考术语的开发、评估和使用，并将其整合到综合医疗保健数据标准中。使用此类标准在电子健康记录中表示护理知识、术语、流程和信息，将提高护理的连续性、决策支持以及可比患者信息的交换。作为此项活动的一部分，2001年、2002年和2003年峰会会议的工作组研究了如何在健康级别7（HL7）参考信息模型（RIM）中表示护理信息。
工作组将护理过程表示为一个动态的阶段序列，每个阶段都包含特定于该阶段活动的信息。他们使用统一建模语言（UML）在模型中表示此领域知识。活动图用于创建护理过程的动态模型。在创建护理过程每个阶段所使用信息的结构模型后，工作组将该信息映射到HL7 RIM。他们使用护理知识的层次结构作为“关于患者的发现”层次模型的基础。此处报告的建模和映射是探索性和初步的，并非详尽无遗或确定性的。目的是评估按照HL7标准一致表示某些类型护理信息的可行性。
工作组通过对照HL7 RIM类“观察”测试护理术语示例进行了小规模验证。
将患者信息从提议的模型映射到RIM类“观察”是可行的。示例说明了这些模型以及护理术语到HL7 RIM的映射。
可以将护理信息建模并映射到综合医疗保健信息模型HL7 RIM中。这些模型必须不断发展并由临床医生进行进一步验证。在信息模型中整合护理信息、术语和流程是使护理信息在电子患者记录和消息中能够被机器读取的第一步。经过更多的开发后，最终的实际成果将是为护理文档创建可计算的结构化信息。
