Nursing constraint models for electronic health records: A vision for domain knowledge governance

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Summary

Various forms of electronic health records (EHRs) are currently being introduced in several countries. Nurses are primary stakeholders and need to ensure that their information and knowledge needs are being met by such systems information sharing between health care providers to enable them to improve the quality and efficiency of health care service delivery for all subjects of care. The latest international EHR standards have adopted the openEHR approach of two-level modelling. The first level is a stable information model determining structure, while the second level consists of constraint models or ‘archetypes’ that reflect the specifications or clinician rules for how clinical information needs to be represented to enable unambiguous data sharing. The current state of play in terms of international health informatics standards development activities is providing the nursing profession with a unique opportunity and challenge. Much work has been undertaken internationally in the area of nursing terminologies and evidence-based practice. This paper argues that to make the most of these emerging technologies and EHRs we must now concentrate on developing a process to identify, document, implement, manage and govern our nursing domain knowledge as well as contribute to the development of relevant international standards. It is argued that one comprehensive nursing terminology, such as the ICNP or SNOMED CT is simply too complex and too difficult to maintain. As the openEHR archetype approach does not rely heavily on big standardised terminologies, it offers more flexibility during standardisation of clinical concepts and it ensures open, future-proof electronic health records. We conclude that it is highly desirable for the nursing profession to adopt this openEHR approach as a means of documenting and governing the nursing profession's domain knowledge. It is essential for the nursing profession to develop its domain knowledge constraint models (archetypes) collaboratively in an international context.

Introduction

Successful management of information, knowledge, information systems and technology is crucial in modern health care organisations to provide competitive advantage, support clinical decision-making, patient management, financial management, resource planning, resource allocation, priority-setting, strategic management and to change organisational processes. Health care organisations operate in a dynamic environment, and consequently, must be able to collect information or knowledge, such as evidence-based clinical or best practice guidelines as required, communicate internally and externally, apply new or existing knowledge and process information so that managers and clinicians can make decisions quickly and effectively. Typically, different systems have been designed to serve the different functions within a health care setting. The challenge is to design systems that can serve a range of functions and/or to integrate information systems such that semantic interoperability is achieved. System integration can be technologically difficult and tends to be costly [1], unless all systems comply with the same set of messaging/communication standards that:

  • support medico-legal accountability and privacy;

  • enable fast information retrieval;

  • support unambiguous clinical information representation;

  • ensure that the EHR contains meaningful and valid information;

  • enable key patient information sharing between individual care providers;

  • facilitate communication regarding request/instruction activation or completion in shared care environments;

  • support the ability to extend the system to meet new information requirements without having to rebuild systems.

The openEHR approach of two-level modelling is able to meet these needs. The first level is a stable information model determining structure, while the second level consists of constraint models or ‘archetypes’ that reflect the specifications or clinician rules for how clinical information needs to be represented to enable unambiguous data sharing.

The overall aim of this paper is to explore to what extent nursing constraint models (archetypes), as defined by the openEHR foundation, can improve semantic system interoperability and enhance the benefits to be obtained by the introduction of EHRs. Within the context of the current state of play, we will:

  • describe ontology-based knowledge domain constraints models (archetypes) and how these relate to EHRs;

  • explore how terminologies may be used to describe the many nursing concepts that make up these models (archetypes);

  • highlight advantages of standardising nursing archetypes and their link with the adoption of evidence-based practice;

  • show why the nursing profession needs to adopt domain knowledge governance protocols.

Section snippets

Current state of play

Every day, new technologies become available claiming to offer solutions for a range of business problems. There are a number of technologies and initiatives that are being adopted by the health industry, such as improvements to supply chain management, evidence-based practice, use of the Internet to deliver health products, intranets and implementation of electronic health records. One of these new technologies is the freely available Archetype Editor downloadable from the openEHR webpages (//www.openehr.org/

Nursing constraint models (archetypes)

Nurses as a profession need to take charge of managing their domain knowledge. We need to develop a framework for managing archetypes and for identifying which need to be standardised, which are nursing domain specific. Nurses need to work in multidisciplinary teams to ensure that those archetypes that meet many clinical user needs adequately meet nursing information needs. We need to minimise redundancy.

We suggest that the current full draft international ISO standard-integration of a

Conclusion

We need to take note of changes currently taking place, consider the long term implications, activate a paradigm shift in thinking and be pro-active to make the most of the opportunities and challenges confronting us today. It is clear that internationally there is strong desire to develop and implement health information systems that have semantic interoperability. There is a global trend towards the implementation of EHRs along with the desire to make the best possible use of available

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