Research Group in Nursing Diagnostics and developments in integrated EHR

Transcription

1 Research Group in Nursing Diagnostics and developments in integrated EHR Wolter Paans, Hanze University Helen de Graaf, Erasmus University MC The Netherlands

2 Outline Research agenda on e-health Nursing process and structure Sensor technologies and nursing diagnosis Developments multi-disciplinary EHR s Interdisciplinary communication

3 E-Health The transfer of health resources and health care by electronic means. It encompasses three main areas: The delivery of health information, for health professionals and health consumers Using the power of IT and e-commerce to improve public health services The use of e-commerce and e-business practices in health systems management.

4 Research Agenda in Nursing Diagnostics - Content development (NNN validation) -Instrument development (Desicion Support Systems) -Prevalence and accuracy (Documentation) -Diagnostic reasoning (Training development) -Implementation (Phases of EHR-implementation) -Standardized languages (SNL) (Data-base NNN) -Relationship SNL and sensor techniques Müller-Staub, M., & Paans, W. (2013b). Agenda para a pesquisa em diagnosticos de enfermagem. In T. H. Herdman (Ed.), NANDA International: Pronanda: Programa de atualizacao em diagnosticos de enfermagem - Ciclo 1 (Vol. 2, pp ).

5 Nursing Diagnosis and Sensor techniques International Master program sensor techniques in healthcare Linking sensor techniques and nursing diagnoses in the PES structure

6 Nursing Process and structure Assessment -> gather signs and symptoms, etiology Diagnosis -> define problem Planning -> outcome identification Implementation -> interventions Evaluation-> results and re-assess

7 National project Purpose: Joined development of an implementable and accepted standard for transition documentation of patient information involving: - Information structure - Information elements - Terminology systems and coding

8 Continuity of Care Record Developed by clinicians in cooperation with IT American Society of Tests and Materials International, 2003, Sections Snapshot of the EHR Covers 80% of handover items (shift change, setting change) (ASTM E , 2006; Collins et al, 2011; Ferranti et al 200, Odenbreit, M. 2010)

9 Continuity of Care Record 1. Payers 10. Medical Equipment 2. Advance Directives 11. Immunizations 3. Support 12. Vital Signs 4. Functional status 13. Results 5. Problem(s) 14. Procedures 6. Family History 15. Encounters 7. Social History 16. Plan of Care 8. Alerts 17. Healthcare Providers 9. Medications

10 Continuity of Care Record 5. Problem(s) - Problem type Diagnosis Complaint Symptom Finding Physical condition Functional limitation - Name (code) Medical concepts list - Date (start and end) - Status (active/inactive) - Relation with other problem or other CCR section

11 Medical concepts list

12 CCR sections, contents 4. Functional status NOC 5. Problem(s) Snomed-CT, NANDA NDx 14. Procedures Medical procedures thesaurus, NIC, Snomed-CT 16. Plan of Care Goals (NIC), and all above

13 Information: CCR Plan of care N Dx (P) Pain Grieving, anticipatory - E Bone metastasis due to mammaca Loss of function - S Expressed pain Uncurable disease Goals: Pain level 4 (0-10) Adapt to functional disabilities 3 Knowledge, indicator 5 (1-5) Family Coping, indicator 3 (1-5) Interventions: Pain Management Coping enhancement -Activities - Medication management (4dd) - Anticipatory guidance (2) - Information (3) - Active listening (1 dd) - Instructions (1 dd)) - Truth telling (2) - Caregiver Support (1 dd) Results: Pain level 3 Adapt to functional disabilities 2 Knowledge indicator 3 Family Coping, indicator 4

14 References Bruylands M, Paans W, Hediger H, Müller-Staub M. Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation. Int J Nurs Knowl 2013;24(3): Collins, S. A., Stein, D. M., Vawdrey, D. K., Stetson, P. D., & Bakken, S. (2011). Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review. Journal of Biomedical Informatics, 44(4), Ferranti, J. M., Musser, R. C., Kawamoto, K., & Hammond, W. E. (2006). The clinical document architecture and the continuity of care record: a critical analysis. Journal of the American Medical Informatics Association : JAMIA, 13(3), doi: /jamia.m1963 Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract 2010;16(2): Müller-Staub M, Lunney M, Lavin M, Needham I, Odenbreit M, van Achterberg T. Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. Int J Nurs Terminol Classif 2008;19(1):20-27.

15 References Odenbreit M, Entwicklung und Implementierung der elektronischen Pflegedokumentation der SoH AG: Eine Erfolgsstory. Swiss Medical Informatics 2010; 69(2): Paans W, Sermeus W, Nieweg RMB, van der Schans C P. D-Catch instrument: development and psychometric testing of a measurement instrument for nursing documentation in hospitals. J Adv Nurs 2010;66(6): Paans W, Sermeus W, Nieweg RMB, van der Schans C P. Development of a measurement instrument for nursing documentation in the patient record. Stud Health Technol Inform 2009;146: Urquhart C, Currell R, Grant M, Hardiker N. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2009(1):CD CD Westra BL, Delaney CW, Konicek D, Keenan G. Nursing standards to support the electronic health record. Nurs Outlook 2008 Sep-Oct;56(5): e1.

16 Thank you Questions?