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奥马哈系统与有意义的使用:在实践、教育和研究中的应用

The Omaha system and meaningful use: applications for practice, education, and research.

作者信息

Martin Karen S, Monsen Karen A, Bowles Kathryn H

机构信息

Martin Associates, Omaha, NE 68144, USA.

出版信息

Comput Inform Nurs. 2011 Jan-Feb;29(1):52-8. doi: 10.1097/NCN.0b013e3181f9ddc6.

Abstract

Meaningful use has become ubiquitous in the vocabulary of health information technology. It suggests that better healthcare does not result from the adoption of technology and electronic health records, but by increasing interoperability and informing clinical decisions at the point of care. Although the initial application of meaningful use was limited to eligible professionals and hospitals, it incorporates complex processes and workflow that involve all nurses, other healthcare practitioners, and settings. The healthcare community will become more integrated, and interdisciplinary practitioners will provide enhanced patient-centered care if electronic health records adopt the priorities of meaningful use. Standardized terminologies are a necessary component of such electronic health records. The Omaha System is an exemplar of a standardized terminology that enables meaningful use of clinical data to support and improve patient-centered clinical practice, education, and research. It is user-friendly, generates data that can be shared with patients and their families, and enables healthcare providers to analyze and exchange patient-centered coded data. Use of the Omaha System is increasing steadily in diverse practice, education, and research settings nationally and internationally.

摘要

在健康信息技术的词汇中,“有意义的使用”已变得无处不在。这表明,更好的医疗保健并非源于技术和电子健康记录的采用,而是通过增强互操作性并在护理点为临床决策提供信息来实现的。尽管“有意义的使用”最初仅适用于符合条件的专业人员和医院,但它包含了涉及所有护士、其他医疗从业者及医疗环境的复杂流程和工作流程。如果电子健康记录采用“有意义的使用”的优先事项,医疗保健社区将变得更加一体化,跨学科从业者将提供以患者为中心的强化护理。标准化术语是此类电子健康记录的必要组成部分。奥马哈系统是标准化术语的典范,它能使临床数据得到有意义的使用,以支持和改进以患者为中心的临床实践、教育及研究。它用户友好,能生成可与患者及其家属共享的数据,并使医疗保健提供者能够分析和交换以患者为中心的编码数据。在国内和国际的各种实践、教育及研究环境中,奥马哈系统的使用正在稳步增加。

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