Standardized Terminologies for EHRs
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Dr Karen Monsen PhD RN Assistant Professor at the University of Minnesota
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Standardized Terminologies for EHRs
- 1. Meaningful Use of Standardized Terminology to Support the Electronic Health Record Karen A. Monsen Health Informatics New Zealand, Inc. 29 March 2010
- 10. The Omaha System is very simple, easy to understand and use, and is available in the public domain. There are only 42 problems 4 actions 75 content descriptors
- 13. Use Stored Data for:: Reporting activity Evaluating programs Researching quality and effectiveness
- 15. Nursing Interventions as Capsicum Red = Teaching, guidance, and counseling Yellow = Treatments and procedures Orange = Case Management Green = Surveillance
- 17. Cultural Safety Communication with community resources Neighborhood/workplace safety Health care supervision Spirituality
- 25. MMPO Care Plan Issues
- 26. MMPO Care Plan Targets
- 30. Core Problems in Home Care
- 34. Help4U Help4U collaborates closely with health care providers and systems and enhance communication between customers and the health care system.
Notas del editor
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Meaningful use is a multidimensional concept that incorporates complex processes; workflow; interoperability; the exchange and use of health information to best inform clinical decisions; evaluate performance; and improve health care quality (Markle Foundation, 2010; Mosquera, 2009).
- The cornerstones meaningful use have been defined by the National Quality Forum as: (a) Improve quality, safety, efficiency, and reduce health disparities, (b) Engage patients and families, (c) Improve care coordination, (d) Improve population and public health, and (e) Ensure privacy and security protections (United States Department of Health and Human Services, 2010).
- Achieving meaningful use of data is dependent on selecting interface standards for point of care documentation of health needs assessments and health care services and outcomes.
- Nurses have led efforts to develop such standards over the past four decades. The American Nurses Association (ANA) currently recognizes seven interface terminologies: Clinical Care Classification, International Classification of Nursing Practice, NANDA International, Nursing Interventions Classification, Nursing Outcomes Classification, Omaha System, and Peri-operative Nursing Data Set.(ANA, 2006; Lundberg, Warren, Brokel, Bulechek, Butcher, 2008 ) These systems are being implemented in EHRs globally. New clinical data sets that provide essential health assessment and service data are becoming available, and methods for meaningful use of the data are emerging. (Monsen, Martin, Christensen, & Westra, 2009; Monsen, Westra, Yu, Ramadoss, & Kerr, 2009; Monsen, Banerjee, & Das, in press)
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- The Omaha System exists in the public domain, is readily incorporated into electronic documentation systems, and is congruent with standards already selected by New Zealand government. For example, the Omaha System is integrated into SNOMED CT® and Logical Observation Identifiers, Names, and Codes (LOINC®); and registered by Health Level Seven (HL7®) (Omaha System, 2010).
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Adoption of electronic health records (EHR) is thought to be a strategy for obtaining the best value for each health care dollar invested. Value comes from meaningful use of the electronic record, and health data within the record.
- Nurses and other stakeholders in New Zealand have begun to adopt the Omaha System for point of care documentation in electronic health records. Some examples of emerging information systems and projects using or considering the Omaha System are the Royal New Zealand Plunket Society, the Midwifery and Maternity Provider Organisation, Nurse Maude, and Help4U.
- The Royal New Zealand Plunket Society (Plunket) is a nurse-led well child care provider serving 80% of children ages 0-5 in New Zealand, with the goal of ensuring that New Zealand families have the best health outcomes from a continuous wellness framework commencing in early pregnancy and continuing until children are aged five years. The Plunket project envisions consistent collection of health information and use of a shared language for health professionals involved, so that population outcomes can be compared.
- Mapping Plunket data requirements to the Omaha System demonstrated that the Omaha System could be used for documenting the desired assessment and intervention data.
- Based on the data, we can see that the most commonly addressed problems in family health were We are serving childbearing and childrearing families. They face challenges with poverty, housing, and family planning. Public health nurses are helping them deal with mental health, substance use, abuse, and neglect issues. This is the order in which the problems were identified and addressed across agencies.
- The Midwifery and Maternity Provider Organisation has a well developed information system that captures 450 unique assessments and outcomes. Currently there is no standardized system for gathering data on the services midwives provide. Preliminary mapping of Omaha System terms to the MMPO Plan of Care was successful in describing midwifery’s continuity of care focus and holistic approach. There is potential to use the Omaha System to map data fields to Omaha System within the existing record, and to add structured Omaha System documentation to replace free text clinical notes. 90% of midwives currently use this system in paper or electronic format, and the system is also being adopted by other obstetrics providers.
- Meaningful use of Omaha System data to advance health care knowledge and improve health care is expanding globally. New Zealand is in a position to capitalize on a sound infrastructure to support an EHR.