Using valid and reliable terminologies to electronically capture the activities and outcomes of nursing practice. Shona K....
<ul><li>National Health Index (NHI) </li></ul><ul><ul><li>Unique identifier for everyone </li></ul></ul><ul><ul><li>Medica...
<ul><li>Ministry </li></ul><ul><li>Clinicians </li></ul>Commerce (vendors)
What we do not have <ul><li>The ability to describe what nursing does and the difference it makes to the health of New Zea...
It’s not just about validation of the profession Day-to-day structured documentation Plan and record nursing activities De...
To improve practice Terminologies to represent nursing practice (1 terminology may have one or more classification schemes...
What’s happening?  <ul><li>Emphasis upon health outcomes </li></ul><ul><li>Development of data collection tools (ad hoc fa...
What are the options? <ul><li>Develop our own interface (colloquial) terminology </li></ul><ul><li>Import terminologies an...
Getting it right at the user interface <ul><li>Using a reliable and valid tool to collect nursing data  </li></ul><ul><ul>...
<ul><li>Climate of nursing shortage and aging workforce </li></ul><ul><li>If development driven by clinicians </li></ul><u...
<ul><li>Technological change is rapid </li></ul><ul><li>Quality processes like good wine take time </li></ul>
Nursing reference terminology Colloquial or interface nursing terminologies (examples) Multi-disciplinary clinical referen...
A way forward <ul><li>Begin implementation of terminologies at local level that: </li></ul><ul><ul><li>Are valid and relia...
Sustainability ICNP Multi-disciplinary clinical reference nomenclature SNOMED-CT ® Terminology at interface
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Using valid and reliable terminologies to electronically capture the activities and outcomes of nursing practice.

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Shona K. Wilson, RN; BHSc; MA; PhD Student

Professor Jan Duke; Head

Graduate School of Nursing, Midwifery and Health

Published in: Health & Medicine, Education
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Using valid and reliable terminologies to electronically capture the activities and outcomes of nursing practice.

  1. 1. Using valid and reliable terminologies to electronically capture the activities and outcomes of nursing practice. Shona K. Wilson, RN; BHSc; MA; PhD Student Professor Jan Duke; Head Graduate School of Nursing, Midwifery and Health
  2. 2. <ul><li>National Health Index (NHI) </li></ul><ul><ul><li>Unique identifier for everyone </li></ul></ul><ul><ul><li>Medical Warning System (MWS) </li></ul></ul><ul><ul><li>Use mandatory for all providers and services </li></ul></ul><ul><ul><li>Access via secure connection to populate Patient Administration Systems (PAS) – then shared with Clinical Information System (CIS) </li></ul></ul><ul><li>National Minimum Data Set (NMDS) </li></ul><ul><ul><li>Public hospital sector – District Health Boards [DHBs] </li></ul></ul><ul><li>Health Intranet – information to providers </li></ul><ul><li>Active Health Information Service Organisation (HISO) </li></ul><ul><ul><li>HIS-NZ (2005) National Health Information Strategy </li></ul></ul><ul><ul><li>Standards development </li></ul></ul><ul><li>Plans for shared Electronic Health Record (EHR) </li></ul><ul><li>Commitment to SNOMED-CT ® </li></ul><ul><li>Health Provider Index (in process) </li></ul><ul><ul><li>Unique identification of health providers </li></ul></ul><ul><li>Most providers have online clinical decision support </li></ul>What we do have
  3. 3. <ul><li>Ministry </li></ul><ul><li>Clinicians </li></ul>Commerce (vendors)
  4. 4. What we do not have <ul><li>The ability to describe what nursing does and the difference it makes to the health of New Zealanders (in any form) </li></ul><ul><li>But we could… </li></ul><ul><ul><li>by the quality data collection and management of nursing activities and outcomes </li></ul></ul><ul><li>Aggregation of nursing data is a long way off </li></ul><ul><li>Nurses use the systems mostly for information retrieval or free text input </li></ul>
  5. 5. It’s not just about validation of the profession Day-to-day structured documentation Plan and record nursing activities Determine service needs Contracts for services Health outcomes National health data International repositories Improving practice
  6. 6. To improve practice Terminologies to represent nursing practice (1 terminology may have one or more classification schemes in it to classify nursing activities and outcomes) What nurses do and what they achieve Electronic care planning and documentation Improve individual practice Valid and reliable tool (structure) Measure the difference nursing makes to the health of the population
  7. 7. What’s happening? <ul><li>Emphasis upon health outcomes </li></ul><ul><li>Development of data collection tools (ad hoc fashion) </li></ul><ul><ul><li>Lack research or theoretical base </li></ul></ul><ul><ul><li>No match between collections </li></ul></ul><ul><ul><li>Lack integration within clinical information systems (interoperability) </li></ul></ul><ul><li>Nursing data cannot contribute on regional or national basis (ever) </li></ul>
  8. 8. What are the options? <ul><li>Develop our own interface (colloquial) terminology </li></ul><ul><li>Import terminologies and make synonyms to represent practice </li></ul><ul><ul><li>Must meet existing terms and definitions </li></ul></ul><ul><ul><ul><li>OR every change reduces reliability of tool </li></ul></ul></ul><ul><li>Import and use terminologies that have high reliability and validity scores - match with clinical reference terminologies </li></ul><ul><ul><li>Test for congruency with NZ context </li></ul></ul>
  9. 9. Getting it right at the user interface <ul><li>Using a reliable and valid tool to collect nursing data </li></ul><ul><ul><li>Terminology/classification scheme at user interface describes what it is supposed to describe </li></ul></ul><ul><li>Nurses in New Zealand do not and have not used nursing classifications regularly in practice </li></ul><ul><li>Success depends upon large numbers of nurses inputting data </li></ul><ul><ul><li>Unsure of computer literacy </li></ul></ul><ul><ul><li>Limited informatics understanding in workforce </li></ul></ul>
  10. 10. <ul><li>Climate of nursing shortage and aging workforce </li></ul><ul><li>If development driven by clinicians </li></ul><ul><ul><li>Replication of paper world into the systems </li></ul></ul><ul><ul><li>Limited knowledge of the uses for consistent data collection </li></ul></ul><ul><li>If development driven by computing </li></ul><ul><ul><li>May not necessarily capture nursing </li></ul></ul><ul><li>Nursing informatics experts spread between </li></ul><ul><ul><li>Practice </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Research </li></ul></ul><ul><ul><li>Development </li></ul></ul><ul><ul><li>National strategy development </li></ul></ul>
  11. 11. <ul><li>Technological change is rapid </li></ul><ul><li>Quality processes like good wine take time </li></ul>
  12. 12. Nursing reference terminology Colloquial or interface nursing terminologies (examples) Multi-disciplinary clinical reference nomenclature NANDA NIC NOC OMAHA CCC Socio-cultural context that is Aotearoa-New Zealand SNOMED-CT ® ICNP ® Taxonomies Ontology Mapping to sustain meaning
  13. 13. A way forward <ul><li>Begin implementation of terminologies at local level that: </li></ul><ul><ul><li>Are valid and reliable internationally </li></ul></ul><ul><ul><li>Cross map with international clinical reference terminologies (SNOMED-CT, INCP) </li></ul></ul><ul><ul><li>Match with particular nursing service practice settings </li></ul></ul><ul><li>Then data collected may be used beyond local context </li></ul><ul><li>Ensure tight rules to minimise future change </li></ul><ul><li>Collaborate across sector </li></ul><ul><li>Evaluate, evaluate, evaluate </li></ul><ul><li>Educate, educate, educate </li></ul><ul><li>Quality, quality, quality </li></ul>
  14. 14. Sustainability ICNP Multi-disciplinary clinical reference nomenclature SNOMED-CT ® Terminology at interface

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