National Patient Care Services, Kaiser Permanente, Oakland, CA, USA.
Department of Veterans Affairs, Washington, DC, USA.
J Am Med Inform Assoc. 2015 May;22(3):608-14. doi: 10.1093/jamia/ocu026. Epub 2015 Feb 5.
The ability to share nursing data across organizations and electronic health records is a key component of improving care coordination and quality outcomes. Currently, substantial organizational and technical barriers limit the ability to share and compare essential patient data that inform nursing care. Nursing leaders at Kaiser Permanente and the U.S. Department of Veterans Affairs collaborated on the development of an evidence-based information model driven by nursing practice to enable data capture, re-use, and sharing between organizations and disparate electronic health records. This article describes a framework with repeatable steps and processes to enable the semantic interoperability of relevant and contextual nursing data. Hospital-acquired pressure ulcer prevention was selected as the prototype nurse-sensitive quality measure to develop and test the model. In a Health 2.0 Developer Challenge program from the Office of the National Coordinator for Health, mobile applications implemented the model to help nurses assess the risk of hospital-acquired pressure ulcers and reduce their severity. The common information model can be applied to other nurse-sensitive measures to enable data standardization supporting patient transitions between care settings, quality reporting, and research.
跨组织和电子健康记录共享护理数据的能力是改善护理协调和质量结果的关键组成部分。目前,大量的组织和技术障碍限制了共享和比较告知护理的基本患者数据的能力。凯撒永久医疗集团和美国退伍军人事务部的护理领导人合作开发了一个基于证据的信息模型,该模型由护理实践驱动,以实现组织和不同电子健康记录之间的数据捕获、重用和共享。本文描述了一个具有可重复步骤和流程的框架,以实现相关和上下文护理数据的语义互操作性。医院获得性压疮预防被选为原型护士敏感质量指标来开发和测试该模型。在国家协调员办公室的 Health 2.0 开发者挑战赛计划中,移动应用程序实现了该模型,以帮助护士评估医院获得性压疮的风险并降低其严重程度。通用信息模型可应用于其他护士敏感措施,以支持患者在护理环境之间的过渡、质量报告和研究的数据标准化。