30 july 2009 what ihe delivers 1 connecting health information technology to the point of care: the...

130 July 2009 What IHE Delivers

Connecting Health Connecting Health Information Technology Information Technology

to the Point of Care:to the Point of Care:The IHE MethodThe IHE Method

Audrey Dickerson, RN, MS Audrey Dickerson, RN, MS

Marcia Veenstra, RN, MSNMarcia Veenstra, RN, MSN

NI 2009NI 2009

2

Your PresentersYour Presenters

Audrey DickersonAudrey Dickerson

Critical Care Nurse Critical Care Nurse

School of Nursing facultySchool of Nursing faculty

International Health Informatics Technical Committee International Health Informatics Technical Committee SecretarySecretary

Marcia VeenstraMarcia Veenstra

Critical Care NurseCritical Care Nurse

Primary Care Case ManagementPrimary Care Case Management

Healthcare practice and informatics consultantHealthcare practice and informatics consultant

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Presentation OutlinePresentation Outline

Objectives and definitions of terms used Objectives and definitions of terms used in this presentationin this presentation

Problem discussionProblem discussion

What and who is IHEWhat and who is IHE

IHE Nursing Sub-CommitteeIHE Nursing Sub-Committee IHE Nursing ProfilesIHE Nursing Profiles

Connections within the world of Nursing Connections within the world of Nursing InformaticsInformatics

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Objectives for WorkshopObjectives for Workshop

Discuss interoperability related to IHE process Discuss interoperability related to IHE process and implementation profile developmentand implementation profile development

Advance nursing practice no matter where the Advance nursing practice no matter where the patient/nurse interaction occurs.patient/nurse interaction occurs.

Endorse methods of nursing data collection Endorse methods of nursing data collection across care settings and timeacross care settings and time

Encourage participation in the active nursing Encourage participation in the active nursing work of profile development work of profile development

Connect with nursing globally to advance Connect with nursing globally to advance continuity of care through interoperabilitycontinuity of care through interoperability

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Terms and DefinitionsTerms and Definitions

EHREHR:: Electronic Health RecordElectronic Health Record

HIEHIE:: Health Information ExchangeHealth Information Exchange

InteroperabilityInteroperability: : The ability of two or more systems The ability of two or more systems or elements to exchange information and to use the or elements to exchange information and to use the information that has been exchanged. information that has been exchanged. IEEE, 1990IEEE, 1990

Content ProfileContent Profile: A coordinated set of standards-: A coordinated set of standards-based information/data, exchanged between the based information/data, exchanged between the functional components of communicating functional components of communicating healthcare IT systems and devices. healthcare IT systems and devices. IHE, 2004IHE, 2004

OutcomeOutcome: Define the end results of nursing : Define the end results of nursing interventions and are indicators of problem interventions and are indicators of problem resolution or progress toward problem or symptom resolution or progress toward problem or symptom resolution. resolution. ICN, 2009ICN, 2009

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Definitions of the terms used in this Definitions of the terms used in this presentationpresentation





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The ProblemThe Problem

Nursing documentation may stay within Nursing documentation may stay within one system, hospital or ambulatory one system, hospital or ambulatory systemsystem

Too many EHR’s, but not enough EHR’s Too many EHR’s, but not enough EHR’s with interoperable nursing datawith interoperable nursing data

How do we collect nursing data across How do we collect nursing data across care settings and timecare settings and time

How (for example) do we develop best How (for example) do we develop best practices for all 74 year old females with practices for all 74 year old females with heart disease?heart disease?

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Nursing ProcessNursing Process

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Using the Nursing Process tool Using the Nursing Process tool in the Problem Spacein the Problem Space

Gathering/collecting the detailsGathering/collecting the details Data to collect:Data to collect:

• Elements, sequence, frequency, location of care delivery, Elements, sequence, frequency, location of care delivery, • Data setsData sets

Nursing documentationNursing documentation• Thorny question of which terminology to useThorny question of which terminology to use• Format?? Menus?? Flowsheet records?? Narrative??Format?? Menus?? Flowsheet records?? Narrative??

Access the patient dataAccess the patient data• Security Security • Privacy issuesPrivacy issues• ConsumerConsumer• ProviderProvider

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Nursing Process / Problem SpaceNursing Process / Problem Space

Goals/OutcomesGoals/Outcomes Setting the goal for interoperabilitySetting the goal for interoperability

PlanningPlanning StandardsStandards Terminology, NOT specificTerminology, NOT specific

Implementation of a nursing IHE profileImplementation of a nursing IHE profile DevelopingDeveloping TestingTesting DemonstratingDemonstrating

Evaluation of the implementationEvaluation of the implementation Did the profile pass the testingDid the profile pass the testing Does the profile meet expectationsDoes the profile meet expectations

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121212

An 11-year public-private initiative An 11-year public-private initiative

Driven by end-users, IHE improves patient care Driven by end-users, IHE improves patient care by harmonizing electronic health information by harmonizing electronic health information exchange exchange

Enables approved standards to seamlessly pass Enables approved standards to seamlessly pass health information amongst care providers on a health information amongst care providers on a local, regional and national levellocal, regional and national level

IHE products are freely available to allIHE products are freely available to all

What is What is “Integrating the Healthcare Enterprise”??“Integrating the Healthcare Enterprise”??

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IHE: IHE: Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise

Provides a rigorous process for developing Provides a rigorous process for developing integration profiles that address specific real-integration profiles that address specific real-world interoperability challengesworld interoperability challenges

Technically robust specifications, facilitating Technically robust specifications, facilitating ease of implementation into vendor applicationsease of implementation into vendor applications

Conformance testing, integration statements, Conformance testing, integration statements, demonstrationsdemonstrations

IHE is a key component of the national healthcare

IT standards initiative in the US, and around the world

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Standards: Standards: Necessary… not SufficientNecessary… not Sufficient

Standards areStandards are Foundational - interoperable and provide Foundational - interoperable and provide

communicationscommunications Broad - varying interpretations and implementationsBroad - varying interpretations and implementations Narrow - may not consider relationships between Narrow - may not consider relationships between

domainsdomains Plentiful - often redundant or disjointedPlentiful - often redundant or disjointed Focused - standards implementation guides typically Focused - standards implementation guides typically

focus on a single standardfocus on a single standard

Interoperability can only be enabled through a standard process for implementing multiple standards

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Connecting Standards to CareConnecting Standards to Care

It is important to ensure that the implementation of It is important to ensure that the implementation of standards meets clinical and administrative needsstandards meets clinical and administrative needs Clinicians and HIT professionals identify the key Clinicians and HIT professionals identify the key

interoperability problems they faceinteroperability problems they face Providers and industry work together to develop and Providers and industry work together to develop and

make available standards-based solutionsmake available standards-based solutions Implementers are able to follow common guidelines in Implementers are able to follow common guidelines in

purchasing and integrating effective systemspurchasing and integrating effective systems

Interoperability is of high value when there is a shared vision on how to implement standards and processes

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Proven Standards Adoption ProcessProven Standards Adoption Process

Document Use Document Use Case Case RequirementsRequirements

Document Use Document Use Case Case RequirementsRequirements

Identify available Identify available standards (standards (e.g. HL7, e.g. HL7, DICOM, IETF, OASIS)DICOM, IETF, OASIS)

Identify available Identify available standards (standards (e.g. HL7, e.g. HL7, DICOM, IETF, OASIS)DICOM, IETF, OASIS)

Develop Develop technical technical

specificationsspecifications

Develop Develop technical technical

specificationsspecifications

Testing at Testing at ConnectathonsConnectathonsTesting at Testing at ConnectathonsConnectathons

IHE IHE DemonstrationsDemonstrationsIHE IHE DemonstrationsDemonstrations

Products Products with IHEwith IHEProducts Products with IHEwith IHE

Timely access to Timely access to informationinformationTimely access to Timely access to informationinformation

Easy to integrate Easy to integrate productsproductsEasy to integrate Easy to integrate productsproducts

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IHE Profile ProcessIHE Profile Process

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11 Years of Steady Evolution 1998 – 2009

The IHE Development DomainsThe IHE Development Domains

Laying the Groundwork1998

PharmacyNEW 2009

Pathologysince 2006

Radiation Oncologysince 2004

Radiologysince 1998

Cardiologysince 2004

Patient Care Devicessince 2005

Patient Care Coordinationsince 2004

Eye Caresince 2006

QualityResearch & Public Health

since 2006

Laboratorysince 2004

(Healthcare)IT Infrastructure

since 2003

1919191919

IHE Organizational StructureIHE Organizational Structure

Contributing &Participating

Vendors

Regional Deployment

ACCACCEACEP

JAHISJIRAJRS

METI-MLHWMEDIS-DCJAMI

RSNA SFRSFIL

SIRMBIREuroRec

COCIREAR-ECRDRG

ESCMSCMDEC

Professional Societies / SponsorsACPGMSIHIMSS

Global Development

Radiology

Cardiology

ITInfrastructure

Patient CareCoordination

Patient CareDevices

Laboratory

Pathology

Eye CareRadiationOncology

Public Health, Quality and Research

IHE International Board

IHE Europe

IHE North America

France

USA

Canada

IHE Asia-Oceania

Japan

Korea

Taiwan

Netherlands

Spain Sweden UKItaly

Germany

Norway

China

Austria

Australia

Malaysia

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Italy Italy (Genoa Region) and (Genoa Region) and AustriaAustria

Since 2006: 4 Hospitals Since 2006: 4 Hospitals and 500 physician and 500 physician offices.offices.

EMRs import and export EMRs import and export documents from their documents from their local records.local records.

All vendor products All vendor products required to pass IHE-required to pass IHE-Europe connectathon in Europe connectathon in April 2005.April 2005.

Patients chose to join Patients chose to join through one of their through one of their care providercare provider

Lower Austria Region Lower Austria Region (around Vienna) (around Vienna) Deployed in 2007 - Deployed in 2007 - Operational. 1.5 Operational. 1.5 Million patients on-Million patients on-line. 11 hospitals line. 11 hospitals connected. connected.

Use a number of IHE Use a number of IHE profiles: workflow, profiles: workflow, basic framework and basic framework and privacy/security.privacy/security.

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France and NetherlandsFrance and NetherlandsEncourage vendors to Encourage vendors to

submit their products to submit their products to the IHE-Europe the IHE-Europe Connectathon.Connectathon.

Implementation plan Implementation plan under revision.under revision.

Use a number of IHE Use a number of IHE profiles: workflow, basic profiles: workflow, basic framework and framework and privacy/security.privacy/security.

National DMP ProjectNational DMP Project

Dutch “e-Radiology” Dutch “e-Radiology” projectproject NICTIZ: capability IHE NICTIZ: capability IHE

with national with national infrastructureinfrastructure

First application: focus First application: focus on Radiologyon Radiology

Friesland Cardiology Friesland Cardiology NetworkNetwork 5 hospitals (4 5 hospitals (4

Community and one Community and one Specialty Hospital)Specialty Hospital)

Cardiac Patient TransferCardiac Patient Transfer Operational for 6 monthsOperational for 6 months

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USA and CanadaUSA and CanadaHITSPHITSP Lab results distribution Lab results distribution and sharing, Registration and and sharing, Registration and Medication History for Medication History for Consumers, Biosurveillance, Consumers, Biosurveillance, Medication Mgt, etc.Medication Mgt, etc.

2 NHIN-2 Pilots using IHE 2 NHIN-2 Pilots using IHE profiles (Medical Summaries and profiles (Medical Summaries and Lab).Lab).

Several HIEs projects are Several HIEs projects are operational and using of operational and using of HITSP/IHE Profiles:HITSP/IHE Profiles:

Philadelphia and in other Philadelphia and in other parts of Pennsylvaniaparts of Pennsylvania

Vermont Vermont Providence OregonProvidence Oregon Boston Medical Center and Boston Medical Center and

affiliated clinicsaffiliated clinics

Canada Health Canada Health Infoway: Infoway:

image sharingimage sharing Radiology workflow Radiology workflow

Toronto East Network Toronto East Network - Ontario- Ontario

Montreal McGill - Montreal McGill - QuebecQuebec

AlbertaAlberta

British ColumbiaBritish Columbia

Launch Internet Explorer Browser.lnk

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Other International IHE Other International IHE WorkWork

ChinaChina MoH selected Lab profiles for lab info sharing. Two pilots planned for MoH selected Lab profiles for lab info sharing. Two pilots planned for

2009.2009. Imaging planned for ShanghaiImaging planned for Shanghai

Israel, Jordan, Palestinian AuthorityIsrael, Jordan, Palestinian Authority Public Health Info Affinity Domain Public Health Info Affinity Domain Middle east Consortium for infectious Disease SurveillanceMiddle east Consortium for infectious Disease Surveillance Operational-2008Operational-2008

JapanJapan Nagoya region network project operational late 2007. Kobe with imaging Nagoya region network project operational late 2007. Kobe with imaging

info sharinginfo sharing

South AfricaSouth Africa National project launched in 2007. Tender awarded. Operational in 2008.National project launched in 2007. Tender awarded. Operational in 2008.

Spain: CataloniaSpain: Catalonia Close to one million patient records on-line using IHE profilesClose to one million patient records on-line using IHE profiles

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Sharing and Accessing Electronic Health Sharing and Accessing Electronic Health RecordsRecords

IHE offers interoperability for local, regional, specific, or IHE offers interoperability for local, regional, specific, or national health information exchangenational health information exchange

Goal is to enable exchange between providers’ clinical Goal is to enable exchange between providers’ clinical and administrative systems and ancillary IT systemsand administrative systems and ancillary IT systems

Objective is to empower the consumersObjective is to empower the consumers in having in having “shared EHR information” between all of its potential “shared EHR information” between all of its potential healthcare providers (if authorized) and self.healthcare providers (if authorized) and self.

Objective is to empower the providersObjective is to empower the providers in choosing when in choosing when and what information to share, and to trust the and what information to share, and to trust the information they may use in the care of their patients.information they may use in the care of their patients.

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Community

Clinical Encounter

Clinical IT System

Aggregate Patient Info

4-Patient data 4-Patient data presented to presented to

PhysicianPhysician

HIEHIE

Clinic Record Specialist Record

Hospital Record

2-Reference2-Referenceto Records to Records for Inquiryfor Inquiry

Access to Shared Records : IHE-XDSAccess to Shared Records : IHE-XDS

3-Records3-RecordsReturnedReturned

Repository ofRepository ofDocumentsDocuments

Repository ofRepository ofDocumentsDocuments

Index of Index of patients recordspatients records

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A content profile is….A content profile is….

A sharable information component that A sharable information component that can be exchanged..can be exchanged.. Within an HIE using the IHE document sharing Within an HIE using the IHE document sharing

profileprofile Via HIS system using IHE profile standardsVia HIS system using IHE profile standards

Human and/or machine readableHuman and/or machine readable Standards exchange complete structured Standards exchange complete structured

documents documents

A library of reusable profilesA library of reusable profiles

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PCC ProfilesPCC Profiles

Medical Summaries

Emergency Department

Referral

ExchangingPHR

Content

AntepartumCare

Summary

EmergencyDepartmentEncounter Summary

FunctionalStatus

Assessments

2005-062005-062006-072006-072007-082007-082008-09 2008-09 2009-102009-10 I

nte

gra

tio

nC

on

ten

t

Query for Existing Data

AntepartumRecord

ClinicalResearch

ImmunizationRegistryContent

Care Management

Query for Clinical

Guidance

Labor and

Delivery Record

Patient Plan of Care

Pre-Hospital

Care Report

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Problem discussion Problem discussion





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History of IHE and NursingHistory of IHE and Nursing

Early IHE work mostly technical and physician basedEarly IHE work mostly technical and physician based

2006 Nursing Special Interest Group formed and submitted 2006 Nursing Special Interest Group formed and submitted a profile of Functional Status Assessments (FSA)a profile of Functional Status Assessments (FSA)

2007 FSA demonstrated at HIMSS Showcase2007 FSA demonstrated at HIMSS Showcase

2008 Nursing Subcommittee proposed and initiated2008 Nursing Subcommittee proposed and initiated

2009 Patient Plan of Care Profile in development2009 Patient Plan of Care Profile in development

2010 Planned demonstration at HIMSS 2010 in Atlanta. 2010 Planned demonstration at HIMSS 2010 in Atlanta.

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Desired OutcomesDesired OutcomesAvailability of patient and clinical information Availability of patient and clinical information prior to admission/transferprior to admission/transfer

Minimized complications due to early Minimized complications due to early intervention intervention

Safe, effective and evidence based care as a Safe, effective and evidence based care as a result of accurate point of care information result of accurate point of care information

Improved patient/family education Improved patient/family education

Continuity of individualized care plan Continuity of individualized care plan

Use of interoperable nursing data Use of interoperable nursing data communicates health informationcommunicates health information

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Value in IHE NursingValue in IHE NursingThe value of interoperable electronic health records The value of interoperable electronic health records

nursing data includesnursing data includes:: Plan for early interventions with appropriate resources Plan for early interventions with appropriate resources

based on patient acuity including nurse staffing (resource based on patient acuity including nurse staffing (resource maximization)maximization)

Early intervention minimizes complicationsEarly intervention minimizes complications Complete clinical information promotes safety and Complete clinical information promotes safety and

improved outcomesimproved outcomes Continuity of care delivery using a plan of care Continuity of care delivery using a plan of care Promotes safer transfers of care and evidence for Promotes safer transfers of care and evidence for

outcomes improvements outcomes improvements

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IHE Nursing SC PlanningIHE Nursing SC Planning

Development of a process framework to Development of a process framework to house the nursing IHE profileshouse the nursing IHE profiles

Expand the framework for the nursing Expand the framework for the nursing process to be interoperableprocess to be interoperable

Framework will communicate consistency Framework will communicate consistency of care needs in an individualized planof care needs in an individualized plan

Consensus driven, evidence based processConsensus driven, evidence based process

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The IHE Nursing PlanThe IHE Nursing Plan

GoalGoal: Move nursing data between care : Move nursing data between care settings across timesettings across time

Year 1Year 1: Move data from non-hospital : Move data from non-hospital settings into acute care and back settings into acute care and back electronically without regard for vendor electronically without regard for vendor application.application.

Year 2Year 2: Use of the Nursing process, a : Use of the Nursing process, a problem solving method, to provide a problem solving method, to provide a framework for further profile work.framework for further profile work.

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Functional Status Assessment – Functional Status Assessment – Year 1Year 1

ConsiderationsConsiderations

Need to demonstrate value and feasibilityNeed to demonstrate value and feasibility

Scales chosen are evidence-based with strong reliability and validity.Scales chosen are evidence-based with strong reliability and validity.

Widely accepted cross-enterprise or required/recommended by Widely accepted cross-enterprise or required/recommended by accrediting agenciesaccrediting agencies

Content ScalesContent Scales

Numeric Rating Scale (NRS-11) for Pain Numeric Rating Scale (NRS-11) for Pain

Braden Scale for Predicting Pressure Sore RiskBraden Scale for Predicting Pressure Sore Risk©©

Geriatric Depression Scale (GDS)Geriatric Depression Scale (GDS)

Minimum Data Set – Section GMinimum Data Set – Section G

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Use Case Example – FSA Use Case Example – FSA

76 year old resident of Residential Facility76 year old resident of Residential Facility

Increased weakness and lethargyIncreased weakness and lethargy

Complains of chills and refuses to get out of bedComplains of chills and refuses to get out of bed

Assessment findings:Assessment findings: pulse increased, respirations shallowpulse increased, respirations shallow low grade temperature low grade temperature reddened area on coccyx, skin moistreddened area on coccyx, skin moist fasting blood glucose is out of controlfasting blood glucose is out of control

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Combined Workflow/Dataflow DiagramCombined Workflow/Dataflow Diagram

Identifies change in functional assessment,

braden scale and glucose level.

Discusses findings from assessment

and labs

Nurse comparesCurrent assessmentto LTC EHR data and

initiates POC

RHIODocumentExchange

Server

Unit RN updates daily assessments

In the EHR

Attending reviews progress notes

and assessments

Nurse assessesresident

Nurse initiatesphone collaboration

with PCP

PCP reviewspatient status

Transfer Patient?

Yes

Reviews EHR data

Patient transferredto acute care

facility

Hospital admissionnurse reviews

transmitted EHRdata

Pt acuity &staffing

levels rvw

Unit placementdecision based oncurrent pt acuity,& staffing levels

Unit RN assessespatient on

admission to unit

Care providersaddress patient’s

medical issues


In the EHR

Patient regainsstrength,

progressing well


In the EHR

Attending reviewspatient status

DischargePatient to LTC?

Yes

RHIODocumentExchange

Server

Key: Process DecisionNurseEHR

PhysicianEHR

Patient transferredto long-term care

facility End of Process

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Patient Plan of Care Patient Plan of Care Year 2Year 2

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Patient Plan of Care (PPOC) Patient Plan of Care (PPOC)

Use Case: PneumoniaUse Case: Pneumonia

A A 70 year old male is admitted to a hospital unit after 70 year old male is admitted to a hospital unit after presenting to the Emergency Department (ED) with;presenting to the Emergency Department (ED) with; Productive cough and acute rib pain Productive cough and acute rib pain Coughing, increased work of breathing Coughing, increased work of breathing Increased temperature, heart rate and blood pressureIncreased temperature, heart rate and blood pressure Chest x-ray showed bilateral infiltratesChest x-ray showed bilateral infiltrates Lab hematologies showed high White blood cell countLab hematologies showed high White blood cell count

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Patient Plan of Care Patient Plan of Care

Nursing DiagnosisNursing Diagnosis (medical diagnosis Pneumonia)(medical diagnosis Pneumonia)

Respiratory alteration due to ineffective gas exchangeRespiratory alteration due to ineffective gas exchange Acute Pain upon coughing Acute Pain upon coughing

Outcome IdentificationOutcome Identification Stabilize respiratory alterationStabilize respiratory alteration Acute pain within patient acceptable limitsAcute pain within patient acceptable limits

Planning and ImplementationPlanning and Implementation Pulmonary CarePulmonary Care Pain ControlPain Control

EvaluationEvaluation Re-assessment of patient outcomesRe-assessment of patient outcomes

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Using the IHE Process for NursingUsing the IHE Process for Nursing

Discussion Questions:Discussion Questions:

Current nursing issues where you practiceCurrent nursing issues where you practice

Define/describe data elements for nursing care Define/describe data elements for nursing care summaries/transfers/handoverssummaries/transfers/handovers

Implementing nursing interventions and Implementing nursing interventions and accountability for your nursing practiceaccountability for your nursing practice

Interoperability in nursing practice, wInteroperability in nursing practice, what issue in hat issue in your nursing practice could interoperability help your nursing practice could interoperability help solve?solve?

How could you make the IHE nursing profiles be How could you make the IHE nursing profiles be reflected your nursing practice?reflected your nursing practice?

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Key Points Key Points

Use of nursing critical thinking processes Use of nursing critical thinking processes and documentation requirements fit well and documentation requirements fit well into the IHE method.into the IHE method.

IHE provides a proven process for IHE provides a proven process for interoperability between disparate systemsinteroperability between disparate systems

Collection of nursing data across time and Collection of nursing data across time and care settings will allow research to care settings will allow research to determine evidence based practice determine evidence based practice guidelines for the futureguidelines for the future

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Problem discussion Problem discussion





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Advancing the Agenda for Patient CareAdvancing the Agenda for Patient Care

Understand and embrace this initiativeUnderstand and embrace this initiative

Get involved with Profile developmentGet involved with Profile development

Respond to public comment opportunitiesRespond to public comment opportunities

Attend educational workshopsAttend educational workshops

Attend a HIMSS Interoperability ShowcaseAttend a HIMSS Interoperability Showcase

Include IHE Integration Profiles in your RFP’sInclude IHE Integration Profiles in your RFP’s

Participate in IHE CommitteesParticipate in IHE Committees

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Questions and ContactsQuestions and Contacts

Audrey Dickerson RN, MSAudrey Dickerson RN, MS

HIMSS Liaison to IHE Nursing SubcommitteeHIMSS Liaison to IHE Nursing Subcommittee

[email protected]@himss.org

Marcia Veenstra RN, MSNMarcia Veenstra RN, MSN

Co-Chair of Nursing SubcommitteeCo-Chair of Nursing Subcommittee

[email protected]@gmail.com

30 july 2009 what ihe delivers 1 connecting health information technology to the point of care: the...

Documents

nursing processusing

nursing process tool

interoperable nursing

patient care

care settings

care providers

continuity of care

ihe process