School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.
Health System Nursing and Duke Health Technology Solutions, Duke University Health System, Durham, North Carolina, USA.
J Am Med Inform Assoc. 2020 Nov 1;27(11):1732-1740. doi: 10.1093/jamia/ocaa166.
Use of electronic health record data is expanding to support quality improvement and research; however, this requires standardization of the data and validation within and across organizations. Information models (IMs) are created to standardize data elements into a logical organization that includes data elements, definitions, data types, values, and relationships. To be generalizable, these models need to be validated across organizations. The purpose of this case report is to describe a refined methodology for validation of flowsheet IMs and apply the revised process to a genitourinary IM created in one organization. The refined IM process, adding evidence and input from experts, produced a clinically relevant and evidence-based model of genitourinary care. The refined IM process provides a foundation for optimizing electronic health records with comparable nurse sensitive data that can add to common data models for continuity of care and ongoing use for quality improvement and research.
使用电子健康记录数据来支持质量改进和研究正在不断扩大;然而,这需要对数据进行标准化,并在各个组织内部和组织之间进行验证。信息模型(IM)的创建是为了将数据元素标准化为一个逻辑组织,其中包括数据元素、定义、数据类型、值和关系。为了具有通用性,这些模型需要在各个组织之间进行验证。本案例报告的目的是描述一种经过改进的流程表 IM 验证方法,并将修订后的流程应用于在一个组织中创建的泌尿生殖 IM。经过改进的 IM 流程增加了证据和专家的意见,生成了一个具有临床相关性和基于证据的泌尿生殖护理模型。经过改进的 IM 流程为优化电子健康记录提供了基础,这些记录可以使用可比的护士敏感数据,从而为连续性护理和持续用于质量改进和研究的通用数据模型做出贡献。