Interoperability in Nursing. Implementation of ICNP in Poland.

Transcription

1 Interoperability in Nursing. Implementation of ICNP in Poland. Dorota Kilańska RN, MSc, PhD EHealth Council in Nursing at the Center for Health Information Systems MoH ICN-Accredited Centre For ICNP Research & Development at the Medical University of Łódź Iwona Szymańska RN, MSc, Medical University of Lodz

2 Plan of the lecture 1) Recommendations for implementation of ICNP 2) Application of the ICNP in the EHR in Poland 3) Use of the ICNP for knowledge management and patient safety (results of care).

3 2008 Version , Background ICNP(R) development and dissemination in Poland 1989 Resolution of ICN, Seul, South Korea; research - analysis of literature, questionnaire, the first draft of the list of terms, version α, β version and then β2 (PNA involvement in the work in 1999); Conference Translators and Reviewers ICNP, sponsored by the "Tele Nurse & ICN Combra, Portugal; 2005 Version 1.0 1st Polish version; 2009 Version 2.0, PNA Recommendation & Policy Statement; 2011 Version Statement MoH/ICN/PNA, support letter of Minister of Administration and Digitization, Statements of Main Chamber Nurses and Midwives (NRPiP), Polish Version of ICNP 2011 (November), 2013 Melbourne Version 4., Recommendation of Ehealth Council in Nursing, CSIOZ - NMDS in Poland, 2015 Version 4 Completed of Polish translation, POLAND 415 activities, lobbying, dissemination, teaching process, researches, & pilot projects.

4 Elektroniczna Electronic Platform Platforma for Gromadzenia, Collection, Analysis Analizy and i U dostępniania Dissemination zasobów of digital resources cyfrowych for omedical Zdarzeniach Events (P1) Medycznych recommendations (P1) rekomendacje WHO STRATEGIA European EUROPEJSKIEGO Strategy KSZTAŁCENIA for PIELĘGNIAREK Nursing and Midwifery WHO 2000 Education, WHO 2000 Recommendations 2004 r. standard ISO FIDS 18104:2003 (Integration of a Reference Terminology Model for Nursing) Komitet Techniczny ISO nr grupa robocza (pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską Międzynarodowego Stowarzyszenia Informatyki Medycznej oraz ICN.

5 Elektroniczna Electronic Platform Platforma Gromadzenia, Collection, Analysis Analizy and i U Dissemination dostępnianiaof zasobów digital resources cyfrowych for Medical o Zdarzeniach Events (P1) Medycznych recommendations (P1) rekomendacje WHO accepted ICNP within WHO STRATEGIA the European WHO FIC to EUROPEJSKIEGO extend Strategy coverage of the KSZTAŁCENIA PIELĘGNIAREK for domain Nursing of nursing and practice WHO as Midwifery 2000 an essential and complementary Education, part of professional WHO health 2000 services Recommendations Mapping ICNP to SNOMED CT I NMDS ICNP Catalogues HOBIC The position of national consultants in the areas of: Oncology Nursing Nursing of the Chronically Ill and Disabled Family Nursing Paediatric Nursing Palliative Care Nursing Psychiatric Nursing regarding the application of the ICNP classification in clinical practice 2004 r. standard ISO FIDS 18104:2003 (Integration of a Reference Terminology Model for Nursing) Komitet Techniczny ISO nr grupa robocza (pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską Międzynarodowego Stowarzyszenia Informatyki Medycznej oraz ICN. Dir 24/2011/UE ehealth Integrated Care EUNRs4CARE

6 The Provisions and Recommendations - The Provisions of the International Council of Nurses( ICN), 22nd May & 20th May Statement of XV National Congress of Delegates of Polish Nurses Association, November Statement of Main Chamber Nurses and Midwives, June 2011, - Statement of National Congress of Delegates NIPiP, December Communique of MoH, ICN & PNA, 3rd July EFN Policy Statement Continuity of Care & EFN Policy Statement of Nursing Sensitive Criteria for the Selection of European Centres of Excellence - The WHO Family of International Classifications The activities of the Polish Nurses Association in implementation ehealth services in nursing

7 The Council of Ministers Directive, dated 12 April 2012, regarding the National Interoperability Framework, the minimal requirements for public records and the exchange of information in electronic form, as well as the minimum requirements for ICT systems INTEROPERABILITY is achieved by: 1. Unification, understood as the application of compatible norms, standards and procedures by the various entities performing public tasks. 2. Interchangeability, understood as the possibility of replacing the product, process or service without simultaneous disruption of information exchange between providers of public tasks or between them and their customers, while meeting all functional requirements of cooperating systems. 3. Compatibility, defined as the suitability of the products, processes or services intended for common use, under specific conditions ensuring provision of essential requirements and the absence of adverse effects (...).

8 REGULATION OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION dated 25 October 2007 regarding the type and range of medical documentation, as well as the method of its processing in health care centres created by the Minister for the Interior ) Information of the state of health and illness, as well as the Nursing Process, diagnosis and treatment or care, including in particular: a) a description of the actions performed by the doctor and nurse b) diagnosis of the health problem, illness or injury The history of the illness comprises: ( ) 2) c. Individual nursing care card; Entries concerning the nursing process are made on a regular basis by the nurse or midwife responsible for the care of the patient, and are checked by the ward manager or senior midwife.

9 REGULATION OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION dated 25 October 2007 regarding the type and range of medical documentation, as well as the method of its processing in health care centres created by the Minister for the Interior 3. The hospital treatment information card comprises: ( ) 4. Recommendations for further treatment, nutrition, nursing and lifestyle; ( ) 5. The section on health and illness associated with of Community Care comprises: 6. Date of commencement and completion of nursing or midwifery care; 7. Type and range of nursing or midwifery activities including the patient and environment, and in particular a recognition of the nursing and psychosocial problems, a care plan of nursing or midwifery actions, together with annotations connected with the performance of activities, including those resulting from the instruction of the doctor; ( )

10 REGULATION OF THE MINISTER OF HEALTH dated regarding the type and scope of medical documentation, as well as the means of its storage 1) 3. Particular individual internal documents are as follows: health record; medical history; newborn medical record; individual nursing care history; individual midwifery care history; visit card; history of the environment and the family assesment. 3.1 To the individual internal documentation is attached a copy of the documentation submitted by the patient, giving information needed for diagnosis, treatment or nursing care. 1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i zakresu dokumentacji medycznej oraz sposobu jej przetwarzania

11 REGULATION OF THE MINISTER OF HEALTH dated regarding the type and scope of medical documentation, as well as the means of its storage 1) 10. Individual records, if the provisions of the Regulation does not provide otherwise, includes: ( ) 3) designation of the person providing health benefits and directing for examination, consultation or treatment : surname and name, job title, obtained specializations number of the profession - in the case of a doctor, nurse and midwife, signature; 4) Date; 5) information on health and disease and the diagnostic process, therapeutic, nursing care or rehabilitation, in particular : description provided health benefits, ( ), recommendations for patient, ( ) 1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i zakresu dokumentacji medycznej oraz sposobu jej przetwarzania

12 DIRECTIVE OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION dated 25 October 2007 regarding the type and range of medical documentation, as well as the method of its processing in health care centres created by the Minister for the Interior DIRECTIVE OF THE MINISTER OF HEALTH dated regarding the type and scope of medical documentation, as well as the means of its storage Nursing Process ICN 2005 Terminology of reference ICNP 1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i zakresu dokumentacji medycznej oraz sposobu jej przetwarzania

13 Projects P1 P6 STRATEGIA EUROPEJSKIEGO KSZTAŁCENIA PIELĘGNIAREK WHO 2000

14 P1.1 "Approach to classifying medical documentation", 3.6 THE USE OF EXISTING TERMINOLOGY of REFERENCE Dictionaries lp. Platform for the Collection, Analysis and Dissemination of digital resources concerning Medical Events The area of terminology Table 6. A list of proposed Terminology of Reference Recomended of Classifications 1. Medications Registry P1 drugs, ATC (Anatomical Therapeutic Chemical Classification System) 2. Social and economic data 3. Recognision 4. Treatment Dictionary of MPiPS; OECD, Social Indicators UNSTATS ICD ( ) ICNP ( ) ICNP used in the actions, the outcomes obtained in nursing care in Nursing (CSIOZ 2013: 29)

15 Platform for the Collection, Analysis and Dissemination of digital resources concerning Medical Events (P1) Attachment no.3 for P1.1 "Approach to classifying medical documentation", category "nursing documentation" - documents: History of the Individual nursing care History of the Individual midwifery care History of Patient Nursing recommendations Fluid balance BP and/or pulse measurements Nurse assessment card History of the Individual care in the family settings PHC Other nursing documentation 05.70????

16 E-DOCUMENTATION Nursing - PROJECT Council Ehealth in nursing (przewodnicząca dr Dorota Kilańska) przy CSIOZ - Center for Health Information Systems Units: ELECTRONIC PATIENT RECORDS Unit (working on: schema of documentation, setting the type of documents included in the nursing documentation and the creation of this document for different areas of nursing) ICNP Team (working on Standards of Nursing Care Plans, using of ICNP Catalogues)

17 Recommendation of The Council for Ehealth in Nursing, CSIOZ MoH, dated September 11, Proposed format of Nursing documentation

18 Council Recommendation of e-health in Nursing at CSIOZ in MZ Recommendation no. 1/2013 dated 11 September The Council for e-health in Nursing and the ICN-Accredited Centre for ICNP Research & Development at the Medical University of Łódź regarding the design of electronic forms of medical documentation in Nursing The Council for e-health in Nursing recommends an introduction to the "Individual Nursing Care Card", indicated in the Directive dated 21 December 2010 regarding the type and scope of medical documentation, as well as the means of its storage 2, provision. 3, point. 4. the following document templates, being an integral part of the cards mentioned above: 1. Nursing interview card; 2. A patient evaluation card, together with a scaled evaluation of patient health, recommended by the International Classification for Nursing Practice (ICNP), which can be found in the attachment to the recommendations below; 3. A plan of care based on the International Classification for Nursing Practice (ICNP ), including the nurse's diagnosis and actions/interventions, as well as outcome described based on the ICNP Classification; 4. Discharge card with instructions for the patient; 5. Nurse's Report; 6. Documents referred to in point. 1) to the point. 5) are the attachments from No. 1 to No. 5 to this Recommendation. It is recommended for creating the architecture of nursing documentation based on the terminology of the International Classification for Nursing Practice (ICNP ).

19 Catalogue ICNP International Classification for Nursing Practice (ICNP )

20 MATERIALS for TEACHERS ICNP Classification, PL version Axis: 1. "diagnoza aktualna negatywna" - DC_negatywna_ICNP_2013.pdf (568 KB) 2. "diagnoza pozytywna" - DC_pozytywna_ICNP_2013_www.pdf (593 KB) "OSIE PODSTAWOWE" 1. "Działania" (A) "Interwencje" (I) 2. "Lokalizacja" (L) 3. "Czas" (T) 4. "Klient" (C) 5. "Środki" (M) 6. "Osąd" (J) 7. Przedmiot opieki (F) przeglądarka ICN

21 Lectures Practical lessons Nursing Practice Seminars Others ICNP topics were discussed # students Bachelor level: Lectures Practical lessons 5014 Nursing practice 1785 Bachelor Bachelor & MSc Not performed Others ICNP in Curricula Results MoH/ACBiR/PNA Questionnaire was sent to 74 schools of nursing Response 23 Professional training # students of Master Degree 9907 Lectures 8337, workshops (Łódź, Bydgoszcz) # Case Studies with using of ICNP 1290 (Nysa, Gdańsk, Lublin, Łódź) Basic Nursing Health Promotion PHC Internal Nursing Surgical Nursing Pediatric Nursing Psychiatric Nursing Informatics Other nursing subjects Others status

22 55 trainings & 1590 Participants (2009, from December 2012 to November 2014) nurses & midwives Postgraduate training 21 lectures (ICN ACR&D, PNA) 3530 Participants 1. Białystok 2. Bydgoszcz 3. Ciechanów 4. Częstochowa 5. Gdańsk 6. Gorzów Wlkp. 7. Jachranka 8. Kalisz 9. Katowice 10. Kielce 11. Kraków 12. Krosno 13. Łódź 14. Nowy Sącz 15. Opole 16. Płock 17. Poznań 18. Radom 19. Rawa Mazowiecka 20. Rzeszów 21. Szczecin 22. Warszawa 23. Włocławek 24. Wrocław 25. Zielona Góra status

23 Paper CF/DSOZ/HKL/2009/076/0797 /W/21897 for the consideration of the introduction to reporting by the NHF health care benefits under the procedures with using ICNP National Health Found (NFZ) buisness meeting Nurses & Midwives Department MoH meeting of the National Consultants PNA lecture 2009 replay to the statements XV KZD (NFZ, Departament Zdrowia Publicznego, KRASZM, CKPPiP) HEALTH POLICY BUSINESS PARTNERS the agreement PNA/KAMSOFT Company 2013/14 consultations 42 pisma w sprawie ( ) Minister of Administration and Digitization to apply to the Ministry of Health to consider buying a Classification for EHR in Poland CSIOZ MoH 2010 ICNP Council (39 meetings) 2012 Ehealth Council in Nursing (17 meetings) 2013 SNOMED CT meeting MoH 2011 Statement ICN/PNA/MoH Communigue on the MoH website, 3 July Significant contribution to the International Classification for Nursing Practice (ICNP) in the interoperability of data in health care

24 evaluation translations wersji 1.0 ( ) 19 meetings (PTP ZG: Warszawa, Gdańsk, Łódź) Translation of ICNP translations version meetings (telekonferencje september 2010 august 2012, PTP ZG) CSIOZ: 2012 agreement for translation of brochures 2013 draft agreement with the ICN on the availability of the ICNP Evaluation translations 3.0 (ACBiR) The agreement with ICN in February 2014 TELENRSCARE Project (April June 2014) 2 meetings Ehealth Council CSIOZ 4 meetings

25 EHR 2017? The computerisation of health protection Business Partners different functionality, diversity of projects, partners lack of cooperation inability to implement good practices the absence of clear indications in legal documents stan r.

26 Translation

27 The results of evaluation of the implementation of the ICNP in clinical practice Group - nurses and midwives participating in ICNP workshops N= = definitely not 2 = not 3 = no opinion 4 = yes 5 = definitely yes

28 Survey N=262 1.Do you see a need for a standardized classification of nursing practice according to ICNP in Poland? Mean response = Will the introduction of the ICNP be possible in your workplace? Mean response= Are you sufficiently prepared to work with the computer in order to implement an electronic nursing documentation system? Mean response= Are you ready to work with ICNP in your practice? Mean response = 3.13

29 European Federation of Nurses Associations The Nurses Voice A Thematic Network to develop Evidence Based Guidelines for Nursing and Social Care on ehealth Services

30 The objective The main objective of the project is the development of evidence based guidelines for the implementation of ehealth services in nursing and social care, building on existing good practices amongst the participants of the Network, sharing and transferring knowledge across the European Economic Area. The ultimate goal of ENS4Care is the establishment of a sustainable mechanism to support nursing and social care research in the field of ICT enabled integrated care. 30

31 Requirements to implement the guideline Stakeholders are recommended to use reference terminology models (such as ICD, ICF, ICNP, ICPC, SNOMED CT), which interpret in the same way the diagnosis, interventions and outcomes. The WHO HIS Strategic Planning Process Guidance should also be considered, and in DRG can include all Care Providers Services (WHO, 2009). Every new device could be assessed by a national Agency, which can be responsible for the evaluation process on all devices needed by individuals and care providers in health care. 31

32 ENS4Care General Assembly Dublin, 22 October 2014

33 ICNP PROJECT PARTNERS Akredytowane Centrum badania i Rozwoju ICNP przy UM w Łodzi

34 "The student asks the master: must one wait long for changes for the better? The master answers: if you want it, EXPECT TO WAIT LONG..."

35 Thank you for your attention Dorota Kilańska ICNP Programme