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ENR AMIA Montreal 2012 V01 (2)
- 1. ENR development in Netherlands Working towards a model based electronic nursing record in practice Niels Jansen, RN, BSN Tino Bekkering, RN, BSN OLVG Hospital, Amsterdam, The Netherlands Dr. William Goossen, Results4Care, The Netherlands 2012-06-26
- 2. Introduction o Who are we? o Why are we here? o Nurse based approach o Modeling in nursing practice
- 3. Setting EHR in Dutch Hospitals o EHR in the Netherlands is booming business o From paper records to digital patient health records o Few vendors in the Dutch market offer a fully integrated EHR with standardizations o Focus in hospitals based on technique rather than: - standardization, - process management - content based with professional knowledge
- 4. Focus EHR Patient safety Patient involvement Decision making
- 5. OLVG hospital in 1 minute
- 6. Project ENR in the OLVG o Focus long term 2011 2020 o Nursing IT organization with nursing professionals with a degree in health informatics o Development of nursing standardization with multi classifications for a solid EHR in the hospital o Short term 2010 - 2015 o Close relationship between Nursing (professionals) and vendor (technique) o Building knowledge of standardization and IT in the nursing organization o Short term ENR solution, bringing standardization of generic forms and patient data
- 7. The start of the project 2010 Collection nursing data (paper forms) 50.000 entries in excel spreadsheet (6 m) 315 unique forms with patient data 5500 records with specific patient data Patient Name 169 entries Patient ID 33 entries Quality indicators 5 forms per patient Fluid Balance 23 forms Allergies 57 entries Vital Signs 41 forms
- 8. Diverse terminology Riva Rocci Tension Blood pressure What is my under pressure???
- 9. Method of standardization • Current standards: ‘pretty solid but hard to move around’ • Focus Professional & Sustainable
- 10. Detail Clinical Models (DCM) Organize workinggroups Determine subjects Review Literature EBP Determine EBN all variables/ context Mapping Coding Working with Design Excel spreadsheets Word templates Program Test Implement Review
- 11. DCM table of content Revision history Care Process Concept Example of instrument Mind map Issues Purpose References Evidence base Functional model Information model (all the variables) Traceability to other standards Example instances Disclaimer Instructions Terms of use Interpretation Copyrights
- 12. Realization Realization of the standardization 2010-2011 Breathing Weight Pupil reaction Nursing assessment (adm.) Heart frequency Oxygen Saturation Blood pressure Length Tube feeding/products Pressure sore risk Long excretion Temperature measurement Pressure sore wound care Stomach excretion Fluids in Pressure sore wound Urination Fluids out classification Defecation Patient admin data Fluid balance Delirium Person data Care Professional data Glasgow Coma Scale Pain score Oxygen admin
- 13. DCM in ENR Steps of processing DCM: • Worddoc • Excelsheet encoding • Functional Design • Development EVD • Database configuration
- 14. Database
- 15. Success o The nursing profession is the leading group o Stimulation of nursing knowledge and research o Spreading the knowledge within the hospital o Medical profession Vital Records – Fluid balance o Close relationship between vendor and nurses
- 16. Next steps
- 17. Questions? Niels Jansen, OLVG William Goossen, Results4Care
Editor's Notes
- Welcome to this presentation where I will explain how the nursing profession, in a dutch hospital, in the centre of Amsterdam has implemented a model based electronic nursing record. Why is this so unique? Standardization and modeling of patient data is well known around the world, but the challenge was how to bring these with the use of an Electronic Health Record into the daily practices. My name is Niels Jansen. I am projectmanager of the project “Electronic Nursing Record and clinical pathways”. My background,… critical care nurse/ paramedic/ Nurse manager pulmonary unit I am also vice chairman of the nursing staff within the OLVG, and in 2009 I initiated this project and in collaboration with the Board of Directors, I formulated the mission of the project.
- The nursing record as part of the larger electronic health record has been discussed for years. Its implementation is not as widespread as often considered. In the Netherlands for example, a fraction of hospitals use it. This presentation describes a nurse led project in a Dutch hospital where an electronic nursing record has been defined. This is based on an requirements analysis and standardization through Detail Clinical Models (DCM). The OLVG is the first hospital in the Netherlands using the DCM method for determining nursing data. In addition, where other HR projects often only use one terminological system, this project uses multiple terminologies. This project was carried out together with Tino Bekkering, an informatics nurse, the OLVG Hospital and William Goossen, an international expert in developing nursing standards. In collaboration with five nurses with a degree in Health Informatics and 25 nurses from the hospital wards, we standardized the patient data with DCM’s, a method and format to organize clinical knowledge, concepts, and data elements. The answer to the question; “How do you transform the theory of standardization & modeling in the daily nursing practice and how is it able to contribute to overall quality of care?” will be further explained in this presentation.
- Registration of patient data drivers with different IT applications and paper records. Little or no standardization based on classifications is applied or integrated in EHR systems
- The focus of EHR development is a growing issue in every country.
- Our hospital, is a known top clinical hospital in Amsterdam, wanted to achieve the goal of introducing an Electronic Nursing Record (ENR). Now we will show you short film of our hospital to get an idea of the setting where we carried out and still carry out this project.
- The project includes a short term ENR solution with limited functions, using standardized generic forms, and a proper nursing record specification for a future long term solution, to be integrated in a multidisciplinary Electronic Health Record (EHR). From the outset, the goal was to have a short term ENR and a long term EHR with the specifications useful in different areas. For this, the standardization approach with DCM was chosen and approved by the hospital board. At the same time we recruited nurses to get a degree in Health Informatics with the goal of building up a Nursing IT organization.
- In 2010, as part of the ENR project, the nurses carried out a complete inventory of all the available forms and documentation methods on 15 wards. All the data was entered into an Excel spreadsheet, sorted, compared, and analyzed accordingly. This took us about six months at the start of the project. The results are shown here. Other steps were: A literature study of ENR specifications, implementations, standardization and modeling to formulate a mission and strategy how to design and implement an ENR Interviews have been held with nurses from the wards, to get to know how nurses use the forms in their daily practice Finally we visited some hospital sites in the Netherlands and in the US to exchange experiences and knowledge of ENR development
- Based on the results of the information analysis, the conclusion was, that there was a large diversity of forms, data entry methods and places and duplication of data. Different forms often included the same data. There was no accepted terminology or data representation and there was a defining of information in different ways. Forms for the same clinical purpose had different names. See, for example, the concept of blood pressure
- Generic forms, such as patient identification, vital signs, fluid balance, and quality indicators such as pain scales, pressure ulcer instruments, and SNAQ were created based on the DCM standardized data, mapped with SNOMED CT, LOINC and others. DCM is both a method and a format to organize clinical knowledge, represent concepts, and define data elements in such a manner that it allows managing and exchanging information without the need to use a specific technology. So why not use nursing terminology systems? Our opinion is that they don’t always have the precise code for every concept. We are looking for the best fit! Explain process with value blood pressure
- The ENR project started with a group of nurses and informatics nurses carrying out the following steps: Sorting out the data in the Excel spreadsheet in logical groupings Next, the data was mapped into consistent categories of patient data. Applying the DCM methodology in which the evidence base for concepts was explored and summarized. The data elements where specified, and meta-information on authorship, version control and publication dates were added. Where required, the informatics nurses added the meta-information and technical descriptions as well.
- The OLVG templates are a variation of the national guidelines for DCM in order to allow the practicing nurses to complete the relevant section. Then the project team encoded the data with technical specifications of the data elements. Everywhere, all the required DCM parts are included.
- The ENR project group realized during the biweekly meetings of 2 hours that within a period of 6 months, a total of 28 DCM’s was developed, of which 9 where localized from within the national repository, and 19 where developed either from scratch, or completed using existing unfinished draft materials.
- Example blood pressure The DCM Word template allowed the nurses to complete the content. They used the Excel spreadsheet to list the data elements. Next, the informatics nurses and external expert completed the technical specification, unique coding, and meta-information. DCM are then placed in the hospitals document management system, allowing governance in the hospitals quality system. The final step is the actual functional design and the system development and implementation. In some instances, the creation of functional design and/or implementation generated new questions. example: measuring the blood pressure at the left or right ankle
- There were some lessons to be learned! It took quite some time for the nurses to start with the creation of DCM and the methodology behind it. Several sessions where needed for education and encouragement. Searching for all the background knowledge remains a time consuming effort. Splitting the DCM into two templates, a Word template for the nursing content and an Excel template for the data element specification, allowed the nurses to concentrate on the professional content. Later, the informatics nurses and an external expert completed the technical parts and coding of the data elements and value sets. The bottom up approach to DCM standardization increased the support and acceptance among nurses. The ENR is recognized as a professional content based system, and not something imposed by some vendor. The quality indicators that are standardized via DCM support the registration of data at the point of care, which has a huge efficiency generating approach. The criteria to choose some data elements from the DCM among others are relevance, time and budget. The project gained external expertise for the standardization of nursing documentation. Another positive effect is that it helps in the discussions with the vendor: requirements are very precise and well specified, making the programming task easier.
- Since the beginning of 2012 we started to implement the ENR with COWS. At the moment 6 wards, around 300 nurses and doctors are using the ENR in the daily practice. At the end of 2012 all 15 wards will be using the ENR. Interview in 30 seconds with nurse behind a COW
- Thank you for listening and your attention