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Standards for nursing content
of electronic records
Anne Casey Information Standards Adviser
Royal College of Nursing, UK
Harnessing technology to promote healthcare efficiency and social inclusion
Advancing the digital agenda for effective and efficient health care
Developing standards for nursing content
Other standards - gaps Clinical governance of standards ‘Patient-centred’ - a nursing view
Nursing content of electronic records
what is written or entered into the (multi-disciplinary) patient record that reflects the nursing contribution to care and outcomes of that care.
Content must: support effective clinical judgements, decisions, care and
communication
reflect core nursing values such as patient focus, partnership working, confidentiality, respect and choice
provide accurate data for commissioning, workforce planning, performance monitoring, quality improvement, and research.
EVIDENCE EXPERTS
PRACTICE STANDARDSIncluding documentation and
audit data requirements
Content of systems based on practice standardsRepresented using standardised terminology
• Improved communication• Support for clinical decision making• Support for evidence based practice• Data for audit, research and management
Minimum acceptable documented neurological observations: • Glasgow coma score; limb movements; pupil size and reactivity; • blood oxygen saturation; respiratory rate; heart rate; blood pressure; temperature.
Government IT programmesHealth informatics standards organisationsTerminology and classification developersAcademic Institutes and Industry partners
Professional organisations
Leadership role – Getting ehealth on the agenda and prioritised
Working with guideline / practice standard developers
Support for ‘technical’ aspects of professional standards: skills, repository management, glossary management
Standards for using ICT in practice
Clinical governance of ehealth standards
National level: Health service & Government standardsRegulator, National Association & specialist groups
International level: ISO TC215, HL7, WHO, IHTSDOICN & international specialist groups
Regional level: Europe CEN TC251EFN & European specialist groups
With support from Informatics specialist groupsIMIA-NI, ACENDIO, EFMI-NI
European Federation of Nurses Associations
Position statement on ehealth October 2009
• ehealth …new, improved, and efficient health era based on technologies that can be safely implemented
• Nursing: major stakeholder; should be closely involved
• Safety risk management and patient centeredness throughout the development lifecycle, including use and discontinuation of technologies
• ehealth developments – must not worsen health inequalities – should support and not hinder the work of clinicians - usability and
human factors standards and development approaches.
Clinical stakeholder participation in the work of ISO TC 215 ISO Technical Report 11487:2008
‘national member bodies to report on measures being taken to engage and facilitate the participation of clinical stakeholders at the domestic level as a basis for further action and to identify models of good practice that other members could adopt’.
Issues: – National representation model: liaison role only (cf IHTSDO)– Volunteers and busy clinicians - funding support?– Routes in to the work and time taken to become expert – How are health informatics standards addressed in clinical
career paths, starting with undergraduate curricula?
‘Patient-centred’?
information centred on the patient access allowed by provider patient has control other models ??
one model does not fit all
Negotiated partnership to
achieve personal health goals
• (ICT) Support for informed decision-making and self management - to the extent preferred / able
• Person is not disadvantaged if she/he cannot or chooses not to make decisions, use technology, give own injections….