Transcript Title of paper

Informatics Enablers and
Resources: The Regulation
and Standards Landscape
Judith J. Warren, PhD, RN, FAAN, FACMI
Consultant
Warren Associates, LLC
Nursing Knowledge: Big Data Research
for Transforming Healthcare
Purpose
• Identify informatics enablers and
resources to support the vision and value
of nursing data for big data research to
transform healthcare.
• Evaluate recommendations for usefulness
in the action plan
HITECH and
Meaningful Use
ACA and Health
Reform
HIPAA
• Transaction and Code Set Standards
• X12
• NCPDP
• National Provider Identifier
National Quality
Forum
• Quality Data Model
• Foundation for eMeasures as required in
Meaningful Use
• Appointed groups
• Health Information Technology Advisory
Committee
• National Priorities Partnership
• Measure Applications Partnership
• Consensus Standards Approval Committee
• NLM’s Value Set Authority Center
Health Level 7
International (HL7)
• The global authority on standards for interoperability of health
information technology with members in over 55 countries
• Messaging standards for all EHRs
• Pressure Ulcer Prevention Domain Analysis Model
• Has terminology bindings
• Continuity of Care Document
Reference
Information Model
(RIM)
Federal Health Architecture
Federal Health Information Model
FHA ensures that
federal agencies
exchange health data
with other public and
private organizations
FHIMS Care Plan
Standards and
Interoperability
Framework
• Use Cases: identify real-world needs; prioritize them through an
open, transparent process; and document explicit, unambiguous use
cases, functional requirements and exchange requirements for
interoperability.
• Standards Harmonization: bridge the gap between different views
of health care information and harmonize them into a consistent
framework to advance interoperability standards.
• Specification Implementation: effective interoperability
specifications
• Reference Implementation: building an executable reference
implementation based on the specifications.
• Integrating the Healthcare Enterprise
• Sample Profiles
• Functional Status Assessments describes the content and
format of Functional Status Assessments that appear
within summary documents.
• Patient Plan of Care exchanges data related to creating
and managing individualized patient care between and
among HIT systems
• Care Management exchanges information between HIT
systems and applications used to manage care for specific
conditions.
• Nursing Note records the act of nursing care delivered to
a patient in the emergency department
Nursing Diagnosis
Nursing Interventions
ISO 18104
Federally Required Terminology Use
• SNOMED CT
• LOINC
• ICD-10-CM
• RxNORM
• CPT
http://www.nlm.nih.gov/research/umls/Snomed/nursing_problemlist_subset.html
Institute of Medicine (IOM)
• Landmark reports
• Computer-base Patient Record
• Now known as Electronic Health Record
• To Err Is Human and the series of Patient Safety and
Quality reports
• The Learning Health System
• Health IT and Patient Safety: Building Safer Systems for
Better Care
• Race, Ethnicity, and Language Data
• Health Literacy
Recommendations
• Design, build and implement health information systems to
comply with regulations and standards
• Participate in standards development to ensure a nursing
voice
• Voice is defined as the data, information, and knowledge that
nurses need to provide and make decisions about safe patient
care
“Learning to use an EHR is more than
documenting the care of a patient. It is learning to
collect and analyze information about a patient
and then passing that information on to the next
clinician who cares for the patient. Only with
quality patient information at the point of care
can clinicians provide safe, effective care.”
Judith J. Warren, 2005