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BUSINESS AND ENTERPRISE SYSTEMS (BES) DIRECTORATE

Organizing Construct : Research from three exemplars in acute-care settings in the United States are described to inform stakeholders about the use of standards that benefit nursing quality measurement and information sharing in healthcare using evidence-based principles. These exemplars, deriving from research studies at Partners HealthCare, Intermountain Healthcare, and Kaiser/VA, focus on measures of pain, falls, and decubitus ulcers. Because each environment used different nursing terminologies, harmonization using broader healthcare standards, including Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT ®) and Logical Observation Identifiers Names and Codes (LOINC®), was necessary to compare data. The steps for acquiring comparability of data are defined. Implications for international nursing standards and recommendations for further research and policy are summarized.

Methods : Through the use of electronic health records (EHR), clinical documentation not only serves to record individual patient experiences but, if the data are collected and reported in a standardized fashion, they can also be aggregated to discern best practices in clinical care which will ultimately lead to improved care and outcomes. Aggregating these data for quality improvement is one form of reuse. To date, quality improvement activities have focused primarily on reuse of medical data. The use of standardized terminology will significantly improve the reuse of nursing data by increasing the ability to share and compare quality data. The ability to share data will enable meaningful analysis of those data for all users who perform clinical care, quality audits, clinical research and other healthcare related operations. Ultimately, the successful sharing of comparable evidence-based healthcare data, including nursing data, will foster improvements in the quality of care(IOM, 2012). The three exemplar populations extracted nursing content based upon clinical practice guidelines. They developed a 10-step, repeatable process to aggregate and harmonize nursing data using SNOMED CT® and LOINC®.