Patient care doesn’t take place at a single site nor is it provided by a single medical specialty. Complex care involves numerous providers, including nursing, collaborating over time which requires the ability to exchange patient information that can be integrated into the health record to increase knowledge. Most existing medical record communications rely on faxes, PDFs, Clinical Document Architecture (CDA) documents and HL7 v2.x messages which succeed at exchanging information, but places a high-burden on the nurses’ attention to insure that critical truths don’t fall through the cracks. Patient care data that is text only cannot facilitate clinical decision support, calculations, or be used to navigate through the clinical workflow. In situations where this may be feasible, patient information collected in one environment should carry with it the context and definition of how it was originally generated to ensure its data integrity. This is considered interoperability.
Semantic interoperability implies that the meaning of the information, in the context it was generated, is properly preserved in the transfer. Although the clinical narrative captured in current generation healthcare systems can support routine care, structured data is needed to support reliable and consistent logic and calculations needed for clinical decision support, quality metrics, clinical research and complex formula based payment models. The achievement of semantic interoperability requires the adoption and use of data standards and exchange all along the care continuum. This presentation will outline the data standards needed to achieve semantic interoperability of nurse collected data.
After participating in this activity, the learner should be better able to:
- Understand the HIT interoperability goals
- Articulate the standard terminologies required for interoperable nursing data
- Discuss an HL7 Clinical Information Modeling Initiative (CIMI) model and how it is used
- Describe an HL7 FHIR resource and how it is used
Susan Matney, PhD, RNC-OB, FAAN
Intermountain Healthcare and the University of Utah College of Nursing
Salt Lake City, UT
Susan Matney is a Medical Informaticist with Intermountain Healthcare and adjunct faculty in the College of Nursing at the University of Utah. She is responsible for developing clinical information models bound to standard terminologies. She represents Intermountain at national/international conferences and organizations, including SNOMED Clinical Terminology (SNOMED CT), Health Level 7 (HL7), Logical Observation Identifiers Names and Codes (LOINC), and American Academy of Nursing (ANA). She is chair of the LOINC nursing subcommittee, past chair of the SNOMED CT nursing special interest group, and current vocabulary facilitator of the HL7 CIMI Working Group.