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Exemplars for the Use of Structured Data in Nursing from Partners Healthcare, Intermountain Healthcare, and Kaiser/VA Collaborative

Three exemplars are described that demonstrate how, in spite of the use of different vendor EHR systems and nursing terminologies, interoperability can be achieved.

These exemplars will demonstrate the value of leveraging structured data in nursing documentation. The selected exemplars use structured terminology in support of interoperability between EHRs, focusing on the concepts of pain management, falls prevention/management, and decubitus ulcers/pressure ulcer risk assessment. These exemplars build on the work nurses have achieved in practice, quality monitoring, and research to develop evidence-based models for nursing care delivery.

Agency for Healthcare Research and Quality (AHRQ) and Partners HealthCare

Each year more than 700,000 people fall in United States hospitals. (Dykes, et al, 2010). Yet fall-prevention guidelines for assessment, interventions, treatment, outcomes, and related toolkits are published and accessible (Dykes, et al, 2013). Recently, the Agency for Healthcare Research and Quality (AHRQ) published the results of a study that outlined a toolkit for overcoming the challenges associated with developing, implementing and sustaining a fall-prevention program (Ganz et al., 2013). This resource is available in the public domain and is designed for interprofessional users. (AHRQ, 2013) The toolkit offers guidance and provides links to tools that can be integrated into EHRs and decision-support systems. Measuring performance over time is key to understanding the effectiveness of the toolkit recommendations.

Performance measurement requires adoption of content frameworks such as the Morse Fall Scale. The standard terminologies to be used to represent nursing content are LOINC® for the assessment items or “questions” and outcome measures, and SNOMED CT® for the assessment “findings” and evidence-based interventions. Adoption and use of the same content standards mapped to common terminology standards enables benchmarking beyond the primary organization. Since the ANA recognized nursing terminologies are mapped into SNOMED CT® and LOINC®, nurses in organizations that have already implemented one terminology such as the Clinical Care Classification System (CCC) can continue to use that terminology and still benchmark with nurses working in organizations that have adopted a different terminology system such as the International Classification of Nursing Practice (ICNP), Nursing Interventions Classification (NIC), or the Omaha System.