Abstract
This chapter describes milestones in the development of electronic health record systems, aiming to highlight the possibilities of interdisciplinary records to advance nursing care. Nursing data is a central element in the electronic documentation of patient care, and the use structures and terminologies facilitate safe and secure information processing and knowledge sharing. Along with patients’ diminishing length of stay, continuity of care needs tools to guarantee care coordination and information sharing between care givers. Only high-quality data can be reused for secondary purposes such as administration, statistics, and research to benefit planning, estimate costs, as well as predict and guide care processes. Nursing care is more often delivered in digital environments where professionals and patients act together.
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References
Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: A review of the research literature. Int J Med Inform. 2008;77:291–304.
Furlow B. Information overload and unsustainable workloads in the era of electronic health records. Lancet Respir Med. 2020;8(3):243–4.
Shull JG. Digital Health and the Sate of Interoperable Electronic Health records. JMIR Med Inform. 2019;7(4):e12712/1-8.
Joukes E, Kiezer N, de Bruijine MC, Abu-Hanna A, Cornet R. Impact of electronic versus paper-based recording before EHR Implementation on health care professionals’ perceptions of EHR use, data quality, and date reuse. Appl Clin Inform. 2019;10(2):199–209. https://doi.org/10.1055/s-0039-1681054.
Donabedian A. The role of outcomes in quality assessment and assurance. Qual Rev Bull. 1992;11:356–60.
Pagulayan J, Eltair S, Faber K. Nurse documentation and the electronic health record. Use the nursing process to take advantage of EHRs’ capabilities and optimize patient care. American Nurse Today. 2018;13(9):58–61.
Kanta Services. The Social Insurance Institution of Finland. 2020. https://www.kanta.fi/en/ Accessed 23 February 2020.
Saranto K, Kinnunen UM, Kivekäs E, Lappalainen AM, Liljamo P, Rajalahti E, Hyppönen H. Impacts of structuring nursing records: a systematic review. Scand J Caring Sci. 2014 Dec;28(4):629–47. https://doi.org/10.1111/scs.12094.
Office of the National Coordinator for Health IT. Standard nursing terminologies: a landscape analysis. Identifying Challenges and Opportunities within Standard Nursing Terminologies. 2017. Available at https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf Accessed March 4, 2020.
Westra BI, Subramanian A, Hart CM, et al. “Achieving” meaningful use “of electronic health records through the integration of the nursing management minimum data set.”. J Nurs Adm. 2010;40(7/8):336–43.
Hübner U, Shaw T, Thye J, Egbert N, de Fatima MH, Chang P, O'Connor S, Day K, Honey M, Blake R, Hovenga E, Skiba D, Ball MJ. Technology informatics guiding education Reform–TIGER. Methods Inf Med. 2018 Jun;57(S 01):e30–42. https://doi.org/10.3414/ME17-01-0155.
Muller-Staub M, de Graaf-Waar H, Paans W. An internationally consented standard for nursing process-clinical decision support systems in electronic health records. Comput Inform Nurs. 2016;34:493–502.
Wieteck P. Furthering the development of standardized nursing terminology through an ENP®-ICNP® cross-mapping. Int Nurs Rev. 2008;55:296–304.
Kim TY, Coenen A, Hardiker N. Semantic mappings and locality of nursing diagnostic concepts in UMLS. J Biomed Inform. 2012;45(1):93–100.
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71.
Puhl RM. What words should we use to talk about weight? A systematic review of quantitative and qualitative studies examining preferences for weight-related terminology. Obes Rev. 2020 Feb 12. 2020; https://doi.org/10.1111/obr.13008.
Kinnunen U-M, Liljamo P, Härkönen M, Ukkola T, Kuusisto A, Hassinen Ti, Moilanen K. User guide, the Finnish care classification system, FinCC 4.0. Finnish Institute for Health and Welfare. 2020. Available: https://www.julkari.fi/handle/10024/140289
Liljamo P, Kinnunen U-M, Saranto K. Health care professionals’ view on the mutual consistency of the Finnish Classification of Nursing Interventions and the Oulu Patient Classification. Scand J Caring Sci. 2016;30:477–88.
Macieira TGR, Chianca TCM, Smith MB, Yao Y, Bian J, Wilkie DJ, Lopez KD, Keenan GM. Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review. J Am Med Inform Assoc. 2019;26(11):1401–11.
White P, Roudsari A. Use of ontologies for monitoring electronic health records for compliance with clinical practice guidelines. Stud Health Technol Inform. 2011;164:103–9.
Goossen WTF, Epping PJMM, Dassen T. Criteria of nursing information systems as a component of the electronic patient record. an international Delphi study. Computer In Nursing. 1997;15(6):307–15.
Safran C, Bloomrosen M, Hammond WF, Labkoff S, Markel-Fox S, Tang PC. Toward a national framework for the secondary use of health data: an American Medical Informatics Association White Paper. J Am Med Inform Assoc. 2007 Jan;14(1):1–9.
Meystre SM, Lovis C, Bürkle G, Tognola A, Lehmann CU. Clinical data reuse or secondary use: current status and potential future progress. IMIA Yearbook of Medical Informatics. 2017:38–52.
Ackley J, Ladwig GB. Nursing diagnosis handbook: an evidence-based guide to planning care. 10th ed. St Louis, MO: Mosby/Elsevier; 2014.
Jefferies D, Johnson M, Griffiths RA. Metastudy of the essentials of quality nursing documentation. Int J Nurs Pract. 2010;16(2):112–24.
Saranto K, Kinnunen U-M. Evaluating nursing documentation–research designs and methods: systematic review. J Adv Nurs. 2009;65(3):464–76.
Mykkänen M, Saranto K, Miettinen M. Nursing Audit as a method for developing nursing care and ensuring patient safety. NI 2012.: 11th International Congress on Nursing Informatics, June 23–27. Montreal, Canada; 2012. https://pubmed.ncbi.nlm.nih.gov/24199107/
Kuusisto A, Asikainen P, Lukka H, Tanttu K. Experiences with the electronic nursing discharge summary. Stud Health Technol Inform. 2009;146:226–30.
Hübner U, Flemming D, Heitmann U, Oemig F, Thun S, Dickerson A, Veenstra M. The need for standardised documents in continuity of care: results of standardizing the eNursing Summary. Stud Health Technol Inform. 2010;160(Pt 2):1169–73.
Matney SA, Warren JJ, Evans JL, Kim TY, Coenen A, Auld VA. Development of the nursing problem list subset of SNOMED CT®. J Biomed Inform. 2012;45(4):683–8. https://doi.org/10.1016/j.jbi.2011.12.003.
Sockolow P, Hellesø R, Ekstedt M. Digitalization of patient information process from hospital to community (home) care nurses: international perspectives. In: Rotegård AK, et al., editors. International Medical Informatics Association (IMIA) and IOS Press; 2018.
Dionisi S, Di Simone E, Alicastro GM, Angelini S, Giannetta N, Iacorossi L, Di Muzio M. Nursing summary: designing a nursing section in the electronic health record. Acta Biomed. 2019;90(3):293–9.
Kuusisto A, Asikainen P, Saranto K. Contents of informational and management continuity of care. Stud Health Technol Inform. 2019 Aug;21(264):669–73. https://doi.org/10.3233/SHTI190307.
Kuusisto A, Asikainen P, Saranto K. Medication documentation in nursing discharge summaries at patient’s discharge from special care to primary care. J Nursing Care. 2014; http://omicsgroup.org/journals/medication-documentation-in-nursing-discharge-summaries-at-patient-discharge-from-special-care-to-primary-care-2167-1168.1000147.pdf/
Kuusisto A, Joensuu A, Nevalainen M, Pakkanen T, Ranne P, Puustinen J. Standardizing key issues from hospital through an electronic multi-professional discharge checklist to ensure continuity of care. Stud Health Technol Inform. 2019 Aug;21(264):664–8. https://doi.org/10.3233/SHTI190306.
Romagnoli KM, Handler SM, Ligons FM, Hochheiser H. Home-care nurses’ perceptions of unmet information needs and communication difficulties of geriatric patients in the immediate post-hospital discharge period. BMJ Quality & Safety. 2013;22(4):324–32.
DESI. The digital economy and society index. Human capital digital inclusion and skills. 2019. Available at: https://ec.europa.eu/newsroom/dae/document.cfm?doc_id=59976
Champlin S, Mackert M, Glowacki EM, Donovan EE. Toward a better understanding of patient health literacy: a focus on the skills patients need to find health information. Qual Health Res. 2017;27:1160–76.
Coughlin SS, Prochaska JJ, Williams LB, et al. Patient web portal, disease management, and primary prevention. Risk Manag Healthc Policy. 2017;10:33–40.
Kruse CS, Krowski N, Rodriquez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfactions: a systematic review and narrative analysis. BMJ Open. 2017;7:e016242.
Omaolo services. 2020. https://www.omaolo.fi/ Accessed June 6th 2020.
Digital Health Village in Finland. 2020. https://www.digitalhealthvillage.com/en/home. Accessed June 6th, 2020.
Sarkar U, Bates DW. Care partners and online patient portals. JAMA. 2017;311(4):357–8.
McAlearney AS, Sieck CJ, Gaughan A, Fareed N, Volney J, Huerta TR. Patients’ perceptions of portal use across care settings: qualitative study. J Med Internet Res. 2019;21(6):e13126.
Anderson MHO, Jackson SL, Oster NV, Peacock S, Walker JD, Chen GY, Elmore JG. Patient typing their own visit agendas into an electronic medical record: pilot in a safety-net clinic. Ann Fam Med. 2017;15(2):158–61.
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Appendix: Answers to Review Questions
Appendix: Answers to Review Questions
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1.
What opportunities do interdisciplinary documentation have?
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(a)
Standardized EHR structure
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(b)
Agreed headings
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(c)
Improved information flow
Explanation: Interdisciplinary documentation is based on a standardized structure, which has agreed headings used in the EHR. When the multidisciplinary team is committed to use a structured EHR, information flow will improve between the team members.
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(a)
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2.
Why must nursing terminologies be evidence-based?
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(a)
In order to show evidence-based patient care
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(b)
In order to develop terminologies based on evidence-based practices
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(c)
So that the end users can refer to evidence-based research
Explanation: Terminologies in use must be evidence-based, and by using terminologies in nursing care documentation, we can make nursing visible and evidence the best possible patient care.
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(a)
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3.
FinCC is an acronym of?
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(a)
Final Clinical Cooperation
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(b)
Finnish Care Classification
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(c)
Finnish Clinical Classification
Explanation: FinCC is an acronym of Finnish Care Classification.
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(a)
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4.
Electronic Nursing Discharge Summary includes:
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(a)
Nursing diagnosis
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(b)
Nursing interventions
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(c)
Nursing outcomes
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(d)
Nursing intensity
Explanation: ENDS is a compact summary of the Nursing Minimum Data Set of the care period, i.e., a summary of nursing diagnoses, nursing interventions, nursing intensity, and nursing outcomes.
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(a)
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5.
What does secondary use of data mean?
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(a)
Clinical data is used a second time.
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(b)
Clinical data is copied to another location in the her.
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(c)
Clinical data is used for a purpose other than that for which it was originally stored.
Explanation: Secondary use of health care data means that data generated in health care activities are used for a purpose other than that for which they were originally stored. The primary patient data in EHR is filtered and combined in different ways for secondary use purposes like operational planning and information management and health care development and innovation. Patient data can be utilized in research, statistics and teaching, and regulatory guidance and control.
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(a)
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6.
How does the digitalization of health care affect interprofessional collaboration or interdisciplinary documentation?
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(a)
Because of digitalization, no interprofessional collaboration is needed in the future.
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(b)
Only health professionals will continue to collaborate.
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(c)
The role of the patient is strengthened, and patients participate, becoming increasingly involved in and responsible for data sharing.
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(d)
Digitalization does not change anything.
Explanation: The development of different kinds of digital services for citizens and health care professionals has enabled service and treatment chains to merge in new ways in different specialized fields in both primary and specialized medical care service networks. Digital health care services allow better cooperation among those working in health care service organizations. Patients will be able to view and produce their own health information as new digital tools and transactional portals are developed. Information systems and electronic identification enable secure patient participation.
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(a)
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7.
What kind of services digitalization (digital transformation) allow?
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(a)
Better cooperation among professionals in social welfare and healthcare service organizations.
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(b)
Patient can store information on his well-being using different applications.
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(c)
Digital services give instruments to improve patient-centered care.
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(d)
Digital services have enabled service and treatment chains to merge in new in different fields in medical care service networks.
Explanation: Digital services have increased customer satisfaction and the impact of services offered to patients or customers while continually gathering data for service development. Digital services allow better cooperation between those working in social welfare and healthcare service organizations. In addition, patient can store information on his wellbeing using different applications. These services have enabled service and treatment chains to merge in new ways in different specialized fields in both primary and specialized medical care service networks.
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(a)
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Saranto, K., Kinnunen, UM., Liljamo, P., Mykkänen, M., Kuusisto, A., Kivekäs, E. (2022). Interprofessional Structured Data: Supporting the Primary and Secondary Use of Patient Documentation. In: Hübner, U.H., Mustata Wilson, G., Morawski, T.S., Ball, M.J. (eds) Nursing Informatics . Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-030-91237-6_14
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