A nursing information model process for interoperability

J Am Med Inform Assoc. 2015 May;22(3):608-14. doi: 10.1093/jamia/ocu026. Epub 2015 Feb 5.

Abstract

The ability to share nursing data across organizations and electronic health records is a key component of improving care coordination and quality outcomes. Currently, substantial organizational and technical barriers limit the ability to share and compare essential patient data that inform nursing care. Nursing leaders at Kaiser Permanente and the U.S. Department of Veterans Affairs collaborated on the development of an evidence-based information model driven by nursing practice to enable data capture, re-use, and sharing between organizations and disparate electronic health records. This article describes a framework with repeatable steps and processes to enable the semantic interoperability of relevant and contextual nursing data. Hospital-acquired pressure ulcer prevention was selected as the prototype nurse-sensitive quality measure to develop and test the model. In a Health 2.0 Developer Challenge program from the Office of the National Coordinator for Health, mobile applications implemented the model to help nurses assess the risk of hospital-acquired pressure ulcers and reduce their severity. The common information model can be applied to other nurse-sensitive measures to enable data standardization supporting patient transitions between care settings, quality reporting, and research.

Keywords: Electronic Health Records; Nursing Information Models; Nursing Research; Nursing documentation; Quality Assurance/Health Care.

MeSH terms

  • Electronic Health Records / organization & administration
  • Electronic Health Records / standards*
  • Evidence-Based Nursing
  • Models, Theoretical
  • Nursing Informatics / standards*
  • Nursing Records / standards*
  • Nursing Research
  • Quality Assurance, Health Care
  • Systems Integration