ABSTRACT
NewYork-Presbyterian Hospital took on the challenge of thinking about innovation differently with the implementation of an innovation unit or iUnit to create the patient care unit of the future. Goals were to understand more about the innovation process and to test new service models, technology platforms, devices, and deployment models. Key findings from the focus groups included the need for additional training and technical support. In general, the initiative was felt to improve overall communication and represents a starting point for further innovation programs.
Subject(s)
Electronic Health Records/standards , Needs Assessment/organization & administration , Nurse's Role , Nursing Care/organization & administration , Nursing Informatics/organization & administration , Nursing Process/organization & administration , Forecasting , Inventions/trends , New York , Organizational InnovationABSTRACT
The use of nursing documents from different electronic health record (EHR) systems is challenging due to inconsistency in document naming across systems and institutions. Mapping each local document name to standard document ontology may enable health care professionals to navigate and retrieve documents efficiently for multiple purposes such as quality assurance, outcomes research or public health reporting. The purpose of this study was to evaluate the sufficiency of the Health Level 7 (HL7)/Logical Observation Identifiers, Names, and Codes (LOINC) document ontology for representing nursing document names. We collected 94 nursing document types from the Eclipsys Clinical Information System (CIS) and the Columbia Medical Entities Dictionary (MED) and mapped them to the components of the HL7/LOINC document ontology. Seventy-five (79.8%) nursing document names were completely represented and 19 (20.2%) document names were partially represented. In order for the HL7/LOINC document ontology to be of more use in implementing EHRs that support nursing documentation, Subject Matter Domain and Type of Service axes require extension and clarification.
Subject(s)
Medical Records Systems, Computerized/standards , Nursing Care , Humans , Medical Records Systems, Computerized/organization & administrationABSTRACT
In our hospital, transition planning for order entry and clinical documentation has presented an opportunity for process changes and the ability to capture quality initiatives into data warehouses, where they can be utilized for building evidence-based practice. For example, the order entry and clinical documentation system allows for data retrieval of performance measures set by organizations including the Joint Commission on Accreditation of Healthcare Organizations, Centers for Medicare & Medicaid Services, and National Quality Forum. These data will reside in one system where they can be mined and extracted for reporting. Details of this magnitude are crucial when developing a CPR that will serve as the primary data source of clinical information. As we continue to seek IT solutions to improve patient safety and provide quality care, the use of informatics as a foundation in quality programs will provide the structure and database needed to support evidence-based practice at the point-of-care and reduce potential for error.
