School of Nursing, University of Minnesota, Minneapolis, MN, USA
Siemens Healthcare, Malvern, PA, USA.
J Am Med Inform Assoc. 2015 May;22(3):600-7. doi: 10.1093/jamia/ocu011. Epub 2015 Feb 10.
There is wide recognition that, with the rapid implementation of electronic health records (EHRs), large data sets are available for research. However, essential standardized nursing data are seldom integrated into EHRs and clinical data repositories. There are many diverse activities that exist to implement standardized nursing languages in EHRs; however, these activities are not coordinated, resulting in duplicate efforts rather than building a shared learning environment and resources.
The purpose of this paper is to describe the historical context of nursing terminologies, challenges to the use of nursing data for purposes other than documentation of care, and a national action plan for implementing and using sharable and comparable nursing data for quality reporting and translational research.
In 2013 and 2014, the University of Minnesota School of Nursing hosted a diverse group of nurses to participate in the Nursing Knowledge: Big Data and Science to Transform Health Care consensus conferences. This consensus conference was held to develop a national action plan and harmonize existing and new efforts of multiple individuals and organizations to expedite integration of standardized nursing data within EHRs and ensure their availability in clinical data repositories for secondary use. This harmonization will address the implementation of standardized nursing terminologies and subsequent access to and use of clinical nursing data.
Foundational to integrating nursing data into clinical data repositories for big data and science, is the implementation of standardized nursing terminologies, common data models, and information structures within EHRs. The 2014 National Action Plan for Sharable and Comparable Nursing Data for Transforming Health and Healthcare builds on and leverages existing, but separate long standing efforts of many individuals and organizations. The plan is action focused, with accountability for coordinating and tracking progress designated.
人们普遍认识到，随着电子健康记录（EHR）的快速实施，大量数据集可用于研究。然而，基本的标准化护理数据很少被整合到 EHR 和临床数据存储库中。有许多不同的活动致力于在 EHR 中实施标准化护理语言；然而，这些活动没有协调，导致重复工作，而不是建立一个共享的学习环境和资源。
本文旨在描述护理术语的历史背景、将护理数据用于护理记录以外的目的所面临的挑战，以及实施和使用可共享和可比护理数据进行质量报告和转化研究的国家行动计划。
2013 年和 2014 年，明尼苏达大学护理学院举办了一次多样化的护士会议，参与了护理知识：大数据和科学改善医疗保健共识会议。召开这次共识会议是为了制定国家行动计划，并协调多个个人和组织现有的和新的努力，加快标准化护理数据在 EHR 中的整合，并确保其在临床数据存储库中可用于二次使用。这种协调将解决标准化护理术语的实施以及随后对临床护理数据的访问和使用。
将护理数据整合到临床数据存储库中用于大数据和科学的基础是在 EHR 中实施标准化护理术语、通用数据模型和信息结构。2014 年用于改善健康和医疗保健的可共享和可比护理数据国家行动计划建立在许多个人和组织现有的、但独立的长期努力基础上，并加以利用。该计划侧重于行动，指定了协调和跟踪进展的责任。
