Use of ICNP-based electronic nur sing documentation system for pr - PowerPoint PPT Presentation

Use of ICNP-based electronic nur sing documentation system for pr actice and research Hyeoun-Ae Park, PhD, RN Professor College of Nursing Seoul National University

Brief history of ICNP in Korea • 1997-2000: Translation of Alpha & Beta versions • 2000-2001: Development of extended Korean ICNP • 2001-2002: Development of a prototype ICNP-based electroni c nursing record system • 2003: Implementation of electronic nursing documentation sys tem at Bundang Seoul National University Hospital • 2005-2006: National standardization of nursing statements • 2008-10: Translation of version 1.0 and version 2.0 • 2011: Development of prototype electronic nursing documenta tion system based on information model and clinical practice g uideline

List of Korean Hospitals with ICNP- based ENR • Already implemented: Bundang SNU Hosp ital, SNU Hospital, Boramae Hospital, Asa n Medical Center, KyungHee Hospital, Cat holic Medical Center, Dongsan Medical Ce nter • Under development: National Cancer Cent er, Ilsan Hospital, Army Hospital

Use of ICNP-based ENR for P ractice

Seoul National University Bundang Hospit al Number of beds: 1003 Number of outpatients per day: 3615 Number of nurses: 845

Relationship between ICNP Concepts, State ments, Catalogues and Patient Records A catalogue item A catalogue ite A catalogue item m A catalogue it A catalogue ite em A catalogue i Patient m A catalogue it A catalogue item tem A catalogue em A catalogue i A catalogue ite item A catalogue A catalogue item tem A catalogue m A catalogue it item A catalogu A catalogue ite em A catalogue i item A catalogue e item m A catalogue it tem A catalogue item A catalogu Records em A catalogue i e item item A catalogue tem A catalogue item A catalogu item A catalogue e item item A catalogu e item Catalogues Extended Kor Statement A Statement B ean ICNP Statement C Statement D Statement E Statement F Statement G Nursing Sta tements

Components of Electronic Nur sing Record System Terminology Server EMR System UIs f U for D r Data En Entry ry Standard rd n nurs rsing data d dictionary ry Population o of I Identification o of statements sta tements new c w concept Store re Retri Re rieve ve Extended ve Ext vers rsion El Electro ronic P Patient of I ICNP Record Re rds

Narrative Nursing Documentation System

Narrative Statements and Catalogues at Bundang SNUH • Number of narrative statements – About 9,000 • Catalogues – 21 common catalogues: ADT, vital sign, eliminatio n, nutrition and diet, activity and rest, medication, pain, transfusion, bleeding, emergency care, sym ptom management, respiratory care, skin care, I/ O, and etc. – 38 nursing unit specific catalogues: Each nursing unit has about 15 different catalogues

Use of data collected with ICN P-based ENR for research

1 st Study • Research question: Is there any difference in terms of quantity and quality of nursing documentation before and after implem entation of ENR? • Method: 20 open heart surgery patients’ paper-based nursing records and another 20 open heart surgery patients’ electronic nursing records were analyzed according to the nursing proc ess and compared in terms of quantity and quality of documen tation. • Result: After the implementation of electronic nursing record s ystem, quantity of nursing records (2.5 times) and the pattern of nursing records following the nursing process have been in creased and granularity of nursing records has been improved . • J Kor Soc Med Informatics 2009;15(1):83-91

2 nd Study • Research question: Are there any gaps between r equired nursing care time based on patient classifi cation and actual nursing care time based on nurs e staffing level? • Methods: We reviewed the nursing records of 124, 416 patients discharged from 2005 to 2007 to ide ntify the gaps in nursing care time. • Results: The pediatric and geriatric units showed r elatively high staffing needs and the trends of und erstaffing over time. • Comput Inform Nurs. 2011 Jul;29(7):419-26.

Comparison of Gaps between Required Nursing Care Time based on Patient Classification and St atus Quo 3.5 F =2.37 F =16.42** 3 F =7.88* F =5.22* F =23.54** F =9.26** F =4.54* 2.5 2 1.5 1 0.5 0 Pediatric ¡nursing ¡ Women's ¡health Surgical ¡nursing Orthopedic ¡& ¡ Medical ¡nursing Psychiatric ¡ Geriatric ¡nursing ¡ rehabilitation ¡ nursing ¡ nursing ¡ 2005 2006 2007

3 rd Study • Research questions: Can we estimate pressure ulcer incidenc e? Are there any practice variations in the nursing intervention provided for preventive pressure-ulcer care to patients with pr essure ulcers or at risk of pressure ulcers? Is there any differe nce in nursing interventions in relation to the patients' medical problems and the characteristics of the nurses who cared for t hem? • The narrative nursing notes of 427 intensive-care patients wh o were discharged in 2007 were analyzed. The frequencies of five nursing interventions for pressure-ulcer prevention were c ompared between pressure-ulcer and pressure-ulcer risk grou ps, as were the characteristics of the nurses who were treatin g the patients in these two groups. Nursing interventions for pr essure-ulcer prevention were also assessed relative to the pat ients' medical problems.

3 rd Study (Cont’d) • Results: The overall incidence of pressure ulcers was 15.0%. Positio n change was the most popular nursing intervention provided for pre ssure-ulcer prevention in both the pressure-ulcer and at-risk groups, followed by skin care. There was a statistically significant tendency t oward a greater frequency of providing skin care and nutritional care in the at-risk group than in the pressure-ulcer group. There was no statistically significant difference in the mean frequencies of nursing i nterventions relative to the patients' medical problems in the pressur e-ulcer group. However, frequencies of nursing interventions did diff er significantly between patients with neurological problems and tho se with other medical problems in the at-risk group. Analysis of the n urses' characteristics revealed that more nursing interventions were documented by those who were younger, less experienced, and mor e educated. Pressure-ulcer prevention care was provided at frequen cies much lower than the recommended guidelines. • Int J Med Inform. 2011 Jan;80(1):47-55.

Variations in Nursing Activities related t o Pressure Ulcers Intensive-­‑care ¡nursing Geriatric ¡nursing ¡ Medical ¡nursing Orthopedic ¡& ¡rehabilitation ¡ nursing ¡ Surgical ¡nursing Women's ¡health Pediatric ¡nursing ¡ 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sensory/mobility ¡assessment Nutritional ¡assessment Ulcer ¡wound ¡care Exercise Position ¡change Skin ¡assessment Use ¡of ¡devices

4 th Study • Research question: Can we estimate the incidence of adverse drug events (ADEs) and the frequency and the duration of na usea by analyzing narrative nursing statements documented i n standardized terminology-based electronic nursing records. • Methods: 156,339 narrative nursing statements documented o ver 3320 days were reviewed for 487 admissions of cancer pa tients who were treated with cisplatin at a tertiary hospital bet ween July 1 and December 31, 2009. Narrative nursing state ments with the terms “adverse drug reaction,” “allergy,” “hyper sensitivity,” and other ADEs associated with cisplatin describe d in the prescription information approved by the Korea Food and Drug Administration were analyzed. In addition, the chara cteristics of one of the ADEs, nausea, were examined further.

4 th Research (Cont’d) • Results: Narrative statements documenting the presence or a bsence of an “adverse drug reaction,” “allergy,” and “hypersen sitivity” were found in 162 (33.3%) of the nursing records of th e 487 patients. Narrative statements documenting the presenc e or absence of ADEs due to cisplatin were found in 476 (97.7 %) of the nursing records. At least 1 ADE was noted in 258 of the 487 patients (53.0%). The presence of nausea was docum ented in 214 (43.9%) of the 487 patients’ nursing records; the mean duration of this nausea was 5.17 days. • Conclusion: ADEs can be monitored by using narrative nursin g statements documented in standardized terminology-based electronic nursing records. • Adverse-Drug-Event Surveillance Using Narrative Statements in Electronic Nursing Records, IJMI (under review)

Next Generation Electronic Nursing Records System § Generating nursing statements based data element models § Developing nursing catalogues based on Clinical Practice Guidelines

Detailed Clinical Model • Data element model consisted of enti ty-attribute-value triplet • Entity: Focus or core concept of data element • Attribute: Qualifier or modifier neede d to describe characteristics of entity in more detail • Value: Possible instances of attribute to realize characteristics of element • Optionality: Indicate if attribute is opti onal or mandatory to describe an ele ment • Data type: type of value an attribute can take