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30 July 2009 What IHE Delivers1
Connecting Health
Information Technology
to the Point of Care:
The IHE Method
Audrey Dickerson, RN, MS
Marcia Veenstra, RN, MSN
NI 2009
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Your Presenters
Audrey Dickerson
Critical Care Nurse
School of Nursing faculty
International Health Informatics Technical Committee
Secretary
Marcia Veenstra
Critical Care Nurse
Primary Care Case Management
Healthcare practice and informatics consultant
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Presentation Outline
Objectives and definitions of terms used in this presentation
Problem discussion
What and who is IHE
IHE Nursing Sub-Committee
IHE Nursing Profiles
Connections within the world of Nursing Informatics
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Objectives for Workshop
Discuss interoperability related to IHE process
and implementation profile development
Advance nursing practice no matter where the
patient/nurse interaction occurs.
Endorse methods of nursing data collection
across care settings and time
Encourage participation in the active nursing
work of profile development
Connect with nursing globally to advance
continuity of care through interoperability
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Terms and Definitions
EHR: Electronic Health Record
HIE: Health Information Exchange
Interoperability: The ability of two or more systems or elements to exchange information and to use the information that has been exchanged. IEEE, 1990
Content Profile: A coordinated set of standards-based information/data, exchanged between the functional components of communicating healthcare IT systems and devices. IHE, 2004
Outcome: Define the end results of nursing interventions and are indicators of problem resolution or progress toward problem or symptom resolution. ICN, 2009
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Presentation Outline
Definitions of the terms used in this presentation
Problem discussion
What and who is IHE
IHE Nursing Sub-Committee
IHE Nursing Profiles
Connections within the world of Nursing Informatics
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The Problem
Nursing documentation may stay within one system, hospital or ambulatory system
Too many EHR’s, but not enough EHR’s with interoperable nursing data
How do we collect nursing data across care settings and time
How (for example) do we develop best practices for all 74 year old females with heart disease?
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Nursing Process
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Using the Nursing Process tool
in the Problem Space
Gathering/collecting the details
Data to collect:
• Elements, sequence, frequency, location of care delivery,
• Data sets
Nursing documentation
• Thorny question of which terminology to use
• Format?? Menus?? Flowsheet records?? Narrative??
Access the patient data
• Security
• Privacy issues
• Consumer
• Provider
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Nursing Process / Problem Space
Goals/Outcomes
Setting the goal for interoperability
Planning
Standards
Terminology, NOT specific
Implementation of a nursing IHE profile
Developing
Testing
Demonstrating
Evaluation of the implementation
Did the profile pass the testing
Does the profile meet expectations
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Presentation Outline
Definitions of the terms used in this presentation
Problem discussion
What and who is IHE
IHE Nursing Sub-Committee
IHE Nursing Profiles
Connections within the world of Nursing Informatics
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An 11-year public-private initiative
Driven by end-users, IHE improves patient care
by harmonizing electronic health information
exchange
Enables approved standards to seamlessly pass
health information amongst care providers on a
local, regional and national level
IHE products are freely available to all
What is
“Integrating the Healthcare Enterprise”??
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IHE:
Integrating the Healthcare Enterprise
Provides a rigorous process for developing
integration profiles that address specific real-
world interoperability challenges
Technically robust specifications, facilitating
ease of implementation into vendor
applications
Conformance testing, integration statements,
demonstrations
IHE is a key component of the national healthcare
IT standards initiative in the US, and around the world
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Standards:
Necessary… not Sufficient
Standards are
Foundational - interoperable and provide
communications
Broad - varying interpretations and implementations
Narrow - may not consider relationships between
domains
Plentiful - often redundant or disjointed
Focused - standards implementation guides typically
focus on a single standard
Interoperability can only be enabled through a standard
process for implementing multiple standards
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Connecting Standards to Care
It is important to ensure that the implementation of
standards meets clinical and administrative needs
Clinicians and HIT professionals identify the key
interoperability problems they face
Providers and industry work together to develop and
make available standards-based solutions
Implementers are able to follow common guidelines in
purchasing 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 Process
Document Use
Case
Requirements
Identify available
standards (e.g. HL7,
DICOM, IETF, OASIS)
Develop
technical
specifications
Testing at
ConnectathonsIHE
Demonstrations
Products
with IHE
Timely access to
informationEasy to integrate
products
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IHE Profile Process
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11 Years of Steady Evolution 1998 – 2009
The 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
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IHE Organizational Structure
Contributing &
Participating
Vendors
Regional Deployment
ACC
ACCE
ACEP
JAHIS
JIRA
JRS
METI-MLHW
MEDIS-DC
JAMI
RSNA
SFR
SFIL
SIRM
BIR
EuroRec
COCIR
EAR-ECR
DRG
ESC
MSC
MDEC
Professional Societies / Sponsors
ACP
GMSI
HIMSS
Global Development
Radiology
Cardiology
IT
Infrastructure
Patient Care
Coordination
Patient Care
Devices
Laboratory
Pathology
Eye CareRadiation
Oncology
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 (Genoa Region) and Austria
Since 2006: 4 Hospitals and 500 physician offices.
EMRs import and export documents from their local records.
All vendor products required to pass IHE-Europe connectathon in April 2005.
Patients chose to join through one of their care provider
Lower Austria Region (around Vienna) Deployed in 2007 -Operational. 1.5 Million patients on-line. 11 hospitals connected.
Use a number of IHE profiles: workflow, basic framework and privacy/security.
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France and Netherlands
Encourage vendors to submit their products to the IHE-Europe Connectathon.
Implementation plan under revision.
Use a number of IHE profiles: workflow, basic framework and privacy/security.
National DMP Project
Dutch “e-Radiology” project
NICTIZ: capability IHE with national infrastructure
First application: focus on Radiology
Friesland Cardiology Network
5 hospitals (4 Community and one Specialty Hospital)
Cardiac Patient Transfer
Operational for 6 months
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USA and CanadaHITSP Lab results distribution and sharing, Registration and Medication History for Consumers, Biosurveillance, Medication Mgt, etc.
2 NHIN-2 Pilots using IHE profiles (Medical Summaries and Lab).
Several HIEs projects are operational and using of HITSP/IHE Profiles:
Philadelphia and in other parts of Pennsylvania
Vermont
Providence Oregon
Boston Medical Center and affiliated clinics
Canada Health Infoway:
image sharing
Radiology workflow
Toronto East Network - Ontario
Montreal McGill -Quebec
Alberta
British Columbia
Launch Internet Explorer Brow ser.lnk
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Other International IHE WorkChina
MoH selected Lab profiles for lab info sharing. Two pilots planned for 2009.
Imaging planned for Shanghai
Israel, Jordan, Palestinian Authority
Public Health Info Affinity Domain
Middle east Consortium for infectious Disease Surveillance
Operational-2008
Japan
Nagoya region network project operational late 2007. Kobe with imaging info sharing
South Africa
National project launched in 2007. Tender awarded. Operational in 2008.
Spain: Catalonia
Close to one million patient records on-line using IHE profiles
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Sharing and Accessing Electronic Health Records
IHE offers interoperability for local, regional, specific, or national health information exchange
Goal is to enable exchange between providers’ clinical and administrative systems and ancillary IT systems
Objective is to empower the consumers in having “shared EHR information” between all of its potential healthcare providers (if authorized) and self.
Objective is to empower the providers in choosing when and what information to share, and to trust the 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
presented to
Physician
HIE
Clinic Record Specialist Record
Hospital Record
2-Reference
to Records
for Inquiry
Access to Shared Records : IHE-XDS
3-Records
Returned
Repository of
Documents
Repository of
Documents
Index of
patients records
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A content profile is….
A sharable information component that
can be exchanged..
Within an HIE using the IHE document sharing
profile
Via HIS system using IHE profile standards
Human and/or machine readable
Standards exchange complete structured
documents
A library of reusable profiles
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PCC Profiles
Medical
Summaries
Emergency
Department
Referral
Exchanging
PHR
Content
Antepartum
Care
Summary
Emergency
Department
Encounter
Summary
Functional
Status
Assessments
2005-06
2006-07
2007-08
2008-09
2009-10
Inte
gra
tio
nC
on
ten
t
Query for Existing Data
Antepartum
Record
Clinical
Research
Immunization
Registry
Content
Care Management
Query for
Clinical
Guidance
Labor
and
Delivery
Record
Patient Plan
of Care
Pre-
Hospital
Care
Report
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Presentation Outline
Problem discussion
Definitions of the terms used in this presentation
What and who is IHE
IHE Nursing Sub-Committee
IHE Nursing Profiles
Connections within the world of Nursing Informatics
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History of IHE and Nursing
Early IHE work mostly technical and physician based
2006 Nursing Special Interest Group formed and submitted a profile of Functional Status Assessments (FSA)
2007 FSA demonstrated at HIMSS Showcase
2008 Nursing Subcommittee proposed and initiated
2009 Patient Plan of Care Profile in development
2010 Planned demonstration at HIMSS 2010 in Atlanta.
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Desired Outcomes
Availability of patient and clinical information
prior to admission/transfer
Minimized complications due to early
intervention
Safe, effective and evidence based care as a
result of accurate point of care information
Improved patient/family education
Continuity of individualized care plan
Use of interoperable nursing data
communicates health information
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Value in IHE NursingThe value of interoperable electronic health records
nursing data includes:
Plan for early interventions with appropriate resources
based on patient acuity including nurse staffing (resource
maximization)
Early intervention minimizes complications
Complete clinical information promotes safety and
improved outcomes
Continuity of care delivery using a plan of care
Promotes safer transfers of care and evidence for
outcomes improvements
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IHE Nursing SC Planning
Development of a process framework to
house the nursing IHE profiles
Expand the framework for the nursing
process to be interoperable
Framework will communicate consistency
of care needs in an individualized plan
Consensus driven, evidence based process
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The IHE Nursing Plan
Goal: Move nursing data between care
settings across time
Year 1: Move data from non-hospital
settings into acute care and back
electronically without regard for vendor
application.
Year 2: Use of the Nursing process, a
problem solving method, to provide a
framework for further profile work.
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Functional Status Assessment – Year 1
Considerations
Need to demonstrate value and feasibility
Scales chosen are evidence-based with strong reliability and validity.
Widely accepted cross-enterprise or required/recommended by
accrediting agencies
Content Scales
Numeric Rating Scale (NRS-11) for Pain
Braden Scale for Predicting Pressure Sore Risk©
Geriatric Depression Scale (GDS)
Minimum Data Set – Section G
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Use Case Example – FSA
76 year old resident of Residential Facility
Increased weakness and lethargy
Complains of chills and refuses to get out of bed
Assessment findings:
pulse increased, respirations shallow
low grade temperature
reddened area on coccyx, skin moist
fasting blood glucose is out of control
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Combined Workflow/Dataflow Diagram
Identifies change in
functional assessment,
braden scale and
glucose level.
Discusses findings
from assessment
and labs
Nurse compares
Current assessment
to LTC EHR data and
initiates POC
RHIO
Document
Exchange
Server
Unit RN updates
daily assessments
In the EHR
Attending reviews
progress notes
and assessments
Nurse assesses
resident
Nurse initiates
phone collaboration
with PCP
PCP reviews
patient status
Transfer
Patient?
Yes
Reviews EHR data
Patient transferred
to acute care
facility
Hospital admission
nurse reviews
transmitted EHR
data
Pt acuity &
staffing
levels rvw
Unit placement
decision based on
current pt acuity,
& staffing levels
Unit RN assesses
patient on
admission to unit
Care providers
address patient’s
medical issues
Unit RN updates
daily assessments
In the EHR
Patient regains
strength,
progressing well
Unit RN updates
daily assessments
In the EHR
Attending reviews
patient status
Discharge
Patient to LTC?
Yes
RHIO
Document
Exchange
Server
Key: Process DecisionNurse
EHR
Physician
EHR
Patient transferred
to long-term care
facility End of Process
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Patient Plan of Care Year 2
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Patient Plan of Care (PPOC)
Use Case: Pneumonia
A 70 year old male is admitted to a hospital unit after
presenting to the Emergency Department (ED) with;
Productive cough and acute rib pain
Coughing, increased work of breathing
Increased temperature, heart rate and blood pressure
Chest x-ray showed bilateral infiltrates
Lab hematologies showed high White blood cell count
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Patient Plan of Care
Nursing Diagnosis (medical diagnosis Pneumonia)
Respiratory alteration due to ineffective gas exchange
Acute Pain upon coughing
Outcome Identification
Stabilize respiratory alteration
Acute pain within patient acceptable limits
Planning and Implementation
Pulmonary Care
Pain Control
Evaluation
Re-assessment of patient outcomes
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Using the IHE Process for Nursing
Discussion Questions:
Current nursing issues where you practice
Define/describe data elements for nursing care
summaries/transfers/handovers
Implementing nursing interventions and
accountability for your nursing practice
Interoperability in nursing practice, what issue in
your nursing practice could interoperability help
solve?
How could you make the IHE nursing profiles be
reflected your nursing practice?
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Key Points
Use of nursing critical thinking processes and documentation requirements fit well into the IHE method.
IHE provides a proven process for interoperability between disparate systems
Collection of nursing data across time and care settings will allow research to determine evidence based practice guidelines for the future
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Presentation Outline
Problem discussion
Definitions of the terms used in this presentation
What and who is IHE
IHE Nursing Sub-Committee
IHE Nursing Profiles
Connections within the world of Nursing Informatics
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Advancing the Agenda for Patient Care
Understand and embrace this initiative
Get involved with Profile development
Respond to public comment opportunities
Attend educational workshops
Attend a HIMSS Interoperability Showcase
Include IHE Integration Profiles in your RFP’s
Participate in IHE Committees
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Questions and Contacts
Audrey Dickerson RN, MS
HIMSS Liaison to IHE Nursing Subcommittee
Marcia Veenstra RN, MSN
Co-Chair of Nursing Subcommittee