The development of a nursing subset of patient problems to support interoperability

BMC Medical Informatics and Decision Making

Research Article

R. A. M. M. Kieft¹  D. M. J. Delnoij²  A. L. Francke³  P. A. Volkert⁴  E. M. de Groot⁵  E. M. Vreeke⁶ 

[1] Dutch Nurses’ Association, PO Box 8212, 3503, Utrecht, RE, Netherlands;National Health Care Institute, PO Box 320, 1110, Diemen, AH, Netherlands;Professor of Transparency in Healthcare from the Patient’s Perspective, Tranzo, Tilburg University, PO Box 90153, 5000, Tilburg, LE, Netherlands;Netherlands Institute for Health Services Research (NIVEL), PO Box 1568, 3500, Utrecht, BN, Netherlands;Amsterdam Public Health Institute/VU Medical Center, Department of Public and Occupational Health, Van der Boechorststraat 7, 1081, Amsterdam, BT, Netherlands;Nictiz - Netherlands Institute for Health IT, PO Box 19121, 2500, The Hague, CC, Netherlands;Nictiz, Dutch National release center of SNOMED CT, PO Box 19121, 2500, The Hague, CC, Netherlands;Nursing Healthcare Innovation Technology Platform of the Dutch Nurses’ Association, PO, Box 8212, 3503, Utrecht, RE, Netherlands;

关键词: Interoperability;    Nursing;    Problem list;    SNOMED ct;    Standardisation;   

DOI  :  10.1186/s12911-017-0567-5

 received in 2017-05-21, accepted in 2017-11-23,  发布年份 2017

来源: Springer

【 摘 要 】

BackgroundSince the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information.MethodsExplorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives.ResultsSixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier.ConclusionsTo support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning.

【 授权许可】

CC BY   
© The Author(s). 2017