Electronic patient care records allow capturing of structured clinical data. In nursing structuring clinical data is seen as an advance since entering of free text is too time consuming and offers little return in terms of systematic documentation and aggregated information about clinical nursing care practice.
The need for structured data in nursing has been addressed by a series of three EU-R&TD-projects launched by the Danish Institute for Health and Nursing Research within the Telematics for Health Care program of DGXIII, viz. Telenursing (1992-1994)1 , Telenurse (1996-1998)2 and TelenurseID-ENTITY (1998-2001)3.
An important part of these projects has focussed on the development of a problem-oriented electronic patient record to document nursing care by means of structured data, in particular data structured according to the so-called nursing process. The nursing process is the generic problem solving strategy as applied to nursing.
In the three projects concerned with telematic applications for nurses the data springing from the steps of the nursing problem-solving process have been structured by means of the International Classification of Nursing Practice (ICNP)45.
Telematic applications, including telematic applications for nurses, should be no islands of information. An important initiative was therefore taken when the Commission services conceived a project aiming at integrating different applications developed within the health telematics program. The envisioned goal of this project was to give flesh and blood to the notion of an integrated electronic patient record where islands of information would be federated through the development of middle-ware based services. Four projects, viz. Synapses, Galen-in-use, I4C and Telenurse-ID-ENTITY, joined this umbrella project named SynEx – Synergy on the Extranet.
Joining SynEx meant for TelenurseID first and foremost participation in an integration effort where the problem-oriented patient record developed might be federated with other applications of the wider hospital environment without having to give up the independent objectives pursued by TelenurseID as such.
The present report will briefly indicate the direction of integration taken by TelenurseID partners in the wake of the SynEx project.
In nursing and the nursing literature a long tradition exists for conceptualising nursing clinical practice in terms of the so-called nursing process. The nursing process as a description of the clinical activities performed by nurses is summarised by the following processes:
However, in nursing the nursing process is accepted not only as a means of conceptualising clinical practice but also as a way to structure nursing documentation. This is only logical as each of the steps of the nursing process as a result produces data and information respectively called: The assessment, the problems/diagnoses, the goals, the interventions and the outcomes.
The nursing process is thus an important framework for structuring documentation of nursing practice but it only marks the start of a trend towards structuring nursing clinical data that is brought to its logical conclusion when also data describing the separate steps of the nursing process are being structured by means of a nursing classification like the International Classification for Nursing Practice (ICNP).
The development of ICNP was mandated by the International Council of Nurses (ICN) representing more than 120 national nurses associations worldwide. The ICNP project thus enjoys a very broad international support. This is the first time that an attempt is made in nursing to develop a common nomenclature and classification.
The development of the International Classification for Nursing Practice encompassing nursing problems/diagnoses, nursing interventions and outcomes is meant to supplement traditional health indicators of mortality and morbidity by adding measurable health indicators related to nursing to the health concept used by the WHO in its policy statement of “Health for All by the Year 2000”.
Ideally the International Classification for Nursing Practice will allow measuring nursing along the following three dimensions:
It goes without saying that this type of information about nursing practice hold promises of making nursing practice measurable in an internationally recognisable way. Thus the results of the measuring nursing practice will make nursing visible in a new and forceful manner.
Problem-oriented documentation of nursing care by means of the nursing process and the use of an International Classification for Nursing Practice as a means of structuring nursing care data pose a double challenge to developers of electronic patient records.
In fact, this double challenge is exactly what has been addressed through the series of three EU-R&TD-projects concerned with telematic applications for nurses mentioned above, viz. Telenursing, Telenurse and TelenurseID-ENTITY.
All three projects are pursuing two general goals, viz. the development of problem-oriented electronic patient records supporting the nursing process and the development and dissemination of the International Classification for Nursing Practice (ICNP) as a reference classification for nursing in Europe.
As part of the TelenurseID project it was the specific task of the Swiss partner (HUG-BI)6, together with the Danish partner (DIHNR), to produce a prototype of an electronic patient record, that would allow the structured documentation of nursing diagnoses, interventions, and outcomes, because these steps of the problem-oriented nursing process are incorporated into the development of an International Classification for Nursing Practice (ICNP).
This prototype named NUREC-DM7 includes both a nursing process manager based upon the general problem solving strategy and a nursing terminology manager based upon the use ICNP as a general frame work for the description of nursing care in electronic nursing records.
The nursing care process manager is a four columns display allowing the recording and the review respectively of nursing problems, goals, nursing interventions, and progress notes. Each data item, i.e. each paragraph in the columns, is composed of a title, a free text description and specific attributes for handling by the care plan manager or by other browsing functions. Multiple links between each data item allow the user to describe the association of problems with other problems, with expected outcomes (goals), care interventions or progress notes. Pre-coded expressions from the establishment catalogue produced by the terminology manager can be used to describe nursing problems, goals and interventions.
The terminology manager is a browser for the ICNP. However, it is also designed to allow the managers of nursing care settings to produce catalogues of pre-coded expressions using the ICNP. The terminology manager thus allows the user to build combined ICNP expressions using both the eight axes of the ICNP nursing phenomena classification and the eight axes of the ICNP nursing intervention classification. The catalogues of pre-combined and pre-coded expressions can be used for the structured documentation of both problems, goals, interventions and outcomes.
The terminology manager allows furthermore the definition of links between expression of the catalogues. Then the nursing care process manager will have the capability of suggesting care interventions to reach care goals or to solve nursing care problems.
It was in particular an important objective of the last of the three projects, viz. the TelenurseID project, to demonstrate the benefits in terms of systematic documentation and aggregated information about clinical nursing care practice of using a problem-oriented record enabled with ICNP8.
A shift of focus happened, however, when TelenurseID joined the EU R&TD project SynEx.
In 1997 the Commission Services urged 4 existing projects of the Telematics for Health Care program of DGXIII, viz. Synapses9, Galen-in-use10, I4C and Telenurse-ID-ENTITY, to enter a joint project with the aim of consolidating, harmonising and integrating their results and applying them to produce products for commercial use. The title of this umbrella project became SynEx – Synergy on the Extranet because it addresses issues inherent in the provision and use of multimedia patient records across large enterprise-wide networks11.
TelenurseID offered an electronic patient record designed according to the problem-oriented nursing process and including a terminology browser designed to support the use of a combinatorial European reference classification, viz. the ICNP.
TelenurseID thus spans both streams within the group of projects of the Health Telematics Program of DGXIII concerned with electronic patient records, viz. the stream concerned with the architecture of electronic patient records and the stream concerned with the structure of classifications and terminologies.
The two action lines of TelenurseID regarding records and terminologies were both brought to bear in relation to the overall objectives of SynEx of bringing together disparate projects with the aim of creating a federated electronic patient record: Nursing terminology was supposed to be integrated in the semantic knowledge base of the federated electronic health care record and key elements of nursing records were supposed to be integrated into the overall architecture of the federated electronic patient record.
From a TelenurseID point of view SynEx offered an excellent opportunity to demonstrate feasibility of integration between the problem-oriented patient record configured to nursing through the use of the ICNP terminology and other health care applications of the wider hospital environment.
The intended role of Telenurse-ID in SynEx is to provide an example of an application being integrated with other applications into a federated electronic health care record through a layer of standard based middle-ware software providing the necessary services.
The two components developed in TelenurseID, viz. the electronic nursing record called NUREC and the browser for the International Classification for Nursing Practice called the ICNP browser, were both to be integrated into the overall SynEx framework according to the following work-plan:
- A first superficial integration was to be demonstrated at the TELECOM99 showing how the care plan and the daily care schedule prepared by a nurse at the hospital could be made available also to the attending physician at his private practice in town using the secure layers of middle-ware solutions.
- A global integration later was to demonstrate the same scenario on a routine basis with dynamic updates of global documents. NUREC was adapted to the official nursing care transmittal sheet designed by the State of Geneva for information exchange between in-patient and home care settings.
- The NUREC data model was then to be matched with that of the DHE in order to prepare the same dynamic integration of the nursing data at the level of single nursing data items, i.e. nursing diagnoses, nursing goals, nursing interventions, and nursing observations and nursing evaluations notes.
The objectives of integration foreseen within the life-time of the SynEx project thus comprised the integration with the DHE of both the TelenurseID record component and the TelenurseID terminology component.
The DHE® (Distributed Healthcare Environment) represents a healthcare-specific middleware implementing a (distributed) repository for all clinical, organisational and managerial information of the healthcare structure, to make them available when and where necessary to all applications in the healthcare information system,developed by the Italian company GESI, co-ordinator of SynEx.
The over 250 data objects and 8.000 data attributes already pre-defined in the DHE ensure the support to the almost totality of the usual requirements of any healthcare information system.
The DHE information model implements and complements the European CEN standard ENV 12967-1 HISA (Health Information Systems Architecture). This standard was developed to promote modular and open systems in health care by specifying a set of common components in terms of their data structure and the services that they offer.
A further CEN standard must be mentioned when talking about electronic health care records, viz. the CEN standard ENV 12265 EHCRA: Electronic Health Care Record Architecture.
ECHRA defines the basic architectural components of electronic patient records and their logical interrelationsship. This standard was developed to facilitate the communication of record components among members of the health care team.
EHCRA complements the CEN HISA standard, and thus, a fortiori, the DHE, by introducing the notion of health care record items. The DHE incorporates the EHCRA provisions regarding health record items on the information model level.
With regard to the TelenurseID record component it has been demonstrated that it complies directly on the application level with the provisions regarding health care record items defined in EHCRA12.
The ICNP classification complies with the European CEN pre-standard (prENV) 14302 NURSYS (Nursing Systems of Concepts) which it has heavily inspired. NURSYS was approved in December 2000.
The integration effort of TelenurseID within the SynEx project thus provides an example of a collaborative effort towards building standard-based nursing information systems1314.
However, in order to build a real standard-based nursing information system ready for the market, it became necessary to supplement the integration exercise to be performed under the laboratory conditions of the SynEx project by an integration task performed under real life conditions. This integration effort was carried in the wake of the SynEx project by the Italian company GESI, the co-ordinator of SynEx, and the Swiss-Danish company named the TeleNurseGroup (TNG) because it is established by members of the TelenurseID consortium involved as full contractual partners in SynEx. TNG is dedicated to research and technological development of nursing and health information systems.
An impression will be provided of how this last integration task was achieved at the conceptual level.
It was a major objective in SynEx to demonstrate that both the categorial structure of the ICNP terminology and the data model of the problem-oriented record might be mapped onto the DHE information model as an integration platform.
The objective of TelenurseID project as part of SynEx was to demonstrate the feasibility of integration between a problem-oriented patient record enabled with a terminology manager configured to support the use of ICNP on one hand and the DHE information model as an integration platform on the other. How this objective was achieved will be described in the following two sections.
The client record developed as part of TelenurseID will need to store the International Classification for Nursing Practice (ICNP) and use it as a starting point for building up ward catalogues to be used for the daily documentation of nursing practice according the steps of the general solving-strategy as interpreted in nursing.
It is beyond the scope of this article to give any detailed description of the ICNP developed so far15. To gain an understanding of the general structure of ICNP it must suffice to know that the ICNP is designed as a multi-axial classification of both nursing phenomena and nursing interventions. Both classifications consist of eight axes:
Nursing phenomena:
Nursing actions:
Each of the two top terms, i.e. Nursing Phenomena and Nursing Actions, are fathers of eight hierarchies or axes. Expressions derived from these hierarchies or axes can be combined. Expressions derived from the eight hierarchies of nursing phenomena might be combined with each other and likewise expressions derived from the eight hierarchies of nursing actions might be combined. Expressions resulting from the combination of expressions from the hierarchies of the nursing phenomena classification are called nursing diagnoses. Expressions resulting from the combination of expressions from the hierarchies of the nursing actions classification are called nursing interventions.
The DHE implements a distributed repository for all clinical, organisational and managerial information of the health care organisation with the scope of making such information available when and where necessary to all applications in the health care information system. Information stored in the DHE may be entered, modified and retrieved through a set of services, which are accessible to the applications by means of stable and public application interfaces that are not depending on any physical or technological environment.
The DHE thus represents a piece of middle-ware, i.e. a software shell that handles operations on data on behalf of applications, which among many other things can manage both diagnostic and procedure classifications as well as classifications of terms, i.e. terminologies; also as a result of its HISA conformance.
In order to decide how to map the classifications onto the DHE information model the semantics of the classifications themselves must be analysed. Such analysis shows that the ICNP classification can be seen as a terminology classification on one hand and as a diagnosis and procedure classification on the other.
Accordingly, the DHE information model manages ICNP both as a set of classified terms and as a diagnosis and procedure classification for different purposes, as explained in the following paragraphs.
The ICNP classifications of Nursing Phenomena and Nursing Actions can from a certain point of view be seen as a set of classified terms, which can be put together to build up the actualdiagnosis and procedure classifications used in the ward catalogues.
It is thus necessary to store the classified terms (i.e. the ICNP classification) “as is”, not only for presentation or browsing purposes but also to use as a baseline for building up the catalogue (diagnostic and procedure classification). Within the DHE such terminology hierarchies are managed through the “semantic category” entity and its sub-super class relationship as in the following figure:
Diagram 1: A high-level representation of the DHE Semantic Category Entity
The DHE semantic category hierarchy, chosen to store the ICNP classification, corresponds to the HISA Concept and Terminology Manager, the scope of which is to manage such hierarchical aggregations.
Mapping the ICNP classification onto the DHE as a terminology classification is, however, only one of the two ways in which the ICNP has been mapped onto the DHE.The ICNP classification has also been mapped onto the DHE as a diagnosis classification and as a procedure classification.
A catalogue is the actual set of problems, causes, signs/ symptoms, goals, interventions and activities built in the ward starting from the basic ICNP classification, according to the way the people of such part of the organisation actually work.
The terms used in the catalogue, built from the original ICNP classification managed as described in the previous section, are structured according to a hierarchy. The user, during a new insertion, will select the node that will act as father to the new node.
Also in these situations, it has been chosen to follow the HISA standard and use the Health Data Manager for what concerns the problems, causes, signs/ symptoms, and goals, all of which identify clinical health data of the patient, while the Activity Management Area has been used for management of interventions and activities.
Each ward of the hospital will have its own catalogue that will be initialised when the system is installed. This has been agreed and has the scope of avoiding that different users in the same ward see different terminologies while treating the same patient.
The catalogue can, however, be modified and updated according to the actual requirements of the nursing staff by inserting new terms either from the ICNP classification or as plain text.
The ward catalogue will have 5 main classes that may not be modified:
problems
causes
signs and symptoms
goals
interventions
activities
Each one of these classes may have several children and the actual hierarchy can be decided/modified during the daily activities of the nursing staff. Only the main classes cannot be chosen as actual problems/interventions/etc. when entering data in the patient record.
Catalogues dealing with problems, causes, signs/symptoms and goals are managed through the Health Datum hierarchy in the DHE as in the following figure:
Diagram 2: A high-level representation of the DHE Health Data Information Model
The Intervention and activity management part (and hierarchy) are organised through the Activity Manager.
Diagram 3: A high-level representation of the DHE Activity Data Information Model
The main classes (problems, causes, signs/symptoms, goals, interventions and activities) are managed through the Class of Health Data and the Class of Activity Data, while the items that can be selected from the hierarchies starting from these classes are managed in the Type of Health Data area and the Type of Activity Data area.
ICNP as a diagnosis and procedure classification has been mapped onto the descriptive parts of the two managers, viz. the Health Data Manager (Nursing Diagnoses, including problems, causes and signs/symptoms, and Goals) and the Activity Data Manager (Nursing Interventions, including Nursing Activities). The descriptive parts include the areas of both Classes and Types. Main classes cannot be instantiated as live patient data. Types of health and activity data, however, can be instantiated in the problem-oriented electronic patient record.
Documenting nursing care of individual patients according to the nursing process, i.e. according to the general problem-solving strategy as applied to nursing is managed through the operational objects of the two data managers of the DHE, viz. the Health Data Manager and the Activity Data Manager.
When the catalogues (identified starting from the original classification) are actually applied to patients, it is useful to notice the distinction between descriptive data and operational data.
The first refers to the ward catalogue itself and identifies the hierarchies of elements through which the user selects items to associate to actual patients (i.e. update the problem-oriented patient record). The other refers to the instantiation of an actual item to a patient. In conformance with HISA the DHE manages these aspects by managing two categories of objects:
The descriptive part of the Health Data Manager and the Activity Data Manager contains the catalogues as such. The operational part contains the data associated to the application of the catalogue data to patients. The organisation criteria and procedures of the specific structure can through these mechanisms be described in the DHE, to guide and support the daily execution of activities.
Introducing the notion of operational data of the problem-oriented electronic patient record is tantamount to introducing the application level concerned with the actual implementation of the integration efforts pursued in SynEx at the conceptual level.
Therefore, a brief outline of the relationship between the mappings onto the DHE information model and the applications built on top of the actual DHE database management system will not be out of the way.
As a result of the three Telenurse projects a problem-oriented electronic patient record has been developed. This record includes a nursing process manager and a terminology manager.
The interface of the nursing process manager as developed in TelenurseID graphically depicts the major steps of the general problem-solving process as applied to nursing.
The nursing process manager applies the general problem-solving strategy to nursing by structuring the daily documentation according to diagnoses, goals, interventions and notes.
The nursing process manager reads individual client data entered about problems, causes, signs/symptoms, goals, interventions and activities from the operational parts of the Health Data Manager and the Activity Data Manager of the DHE. These operational data might technically speaking be described as instantiations of the types of data found in relevant catalogues produced by means of the ICNP and stored in the descriptive part of the Health Data Manager and the Activity Data Manager of the DHE.
The terminology manager is composed of two parts, viz. an expression builder and a catalogue administrator. The two parts of the terminology manager correspond respectively to the left side and the right side of the user interface of the terminology manager.
The two parts of the terminology manager correspond also respectively to the two ways in which the ICNP has been mapped on the DHE.
The expression builder reads the ICNP classification from the “semantic category” hierarchy of the DHE and loads it into the application window.
The expression builder allows the user to build expressions either by typing the expressions (free expressions) or by selecting them from the ICNP (coded expressions). Expressions selected from the ICNP allows the user to build up catalogues of problems, causes, signs/symptoms, goals, interventions and activities.
The expression builder thus relies on mapping the ICNP classification onto the “semantic category” entity of the DHE as a set of classified terms.
The catalogue administrator reads the ICNP classification from the descriptive part of the Health Data Manager (problems, causes, signs/symptoms and goals) and the Activity Data Manager (interventions and activities) hierarchy of the DHE and loads it into the application window.
The catalogue administrator allows the user to manipulate the descriptive data of the catalogue by different commands, including adding free (uncoded) expressions, adding ICNP expressions (coded) created by the terminology builder, editing expressions and removing expressions.
The catalogue administrator relies on mapping the ICNP classification onto the Health Data Manager and the Activity Data Manager of the DHE respectively as a diagnosis classification and as a procedure classification.
The DHE incorporates the ECHRA (CEN ENV Electronic Health Care Record) provisions regarding health record items on the information model level.
The classes of information managed by the Health Data Manager and the Activity Data Manager of the DHE include the description and the classification of various health care record items as well as actual data relating to the values of such data for the individual.
The overall organisation of the Health Data and the Activity Data and the properties of each information thus is conformant with the provisions regarding health care record items defined in EHCRA16.
Independently of the DHE information model it has earlier been demonstrated that the problem-oriented client record of TelenurseID directly on the application level is conformant with the provisions regarding health care record items defined in EHCRA . In fact, the problem-oriented patient record of TelenurseID is amenable to a description by means of record item complexes relating to problems, goals, interventions and notes. Such a description is of particular importance when client record items, and the associated actual operational data, starts to be communicated throughout the wider hospital environment as a result of integration.
The following figure illustrates the relationships between the application level and the level of the DHE as an integration platform by taking into account also the level of European standards according to which this integration effort was performed in the wake of the SynEx project:
Diagram 4: Integration of a standard-based nursing record using the DHE
More details about the application level is the topic for another article on telematic applications for nurses as an example of a SynEx deliverable reaching the market.
From a data point of view the objective of TelenurseID in SynEx has clearly been achieved:
It has been demonstrated that both the categorial structure of the ICNP terminology and the data model of the problem-oriented record can be mapped onto the DHE information model as an integration platform.
From a functional point of view, however, not all objectives have been reached. Both the nursing process manager and the terminology manager.stand in need of at least one major function of vital importance to nursing practice.
During the industrialisation process, i.e. the transformation of the prototype into a product, these two important complemtary functions were lost due to severe time constraints.
The terminology manager of the TelenurseID prototype included a function allowing to pre-define links between expression of the catalogues. This connector function allows to pre-define links between problems, goals and interventions. Also links between problems, causes and signs/symptoms might be pre-defined.
The nursing process manager of the TelenurseID prototype takes advantage of these pre-defined links by suggesting “smart” solutions to the problems of the client.
When a problem is selected in, then the nursing process manager suggests relevant goals to be achieved and when a relevant goal is selected then relevant interventions are suggested to reach these goals. This function of “smart” links between the steps of the general problem-solving strategy has temporarily been lost when the prototype of TelenurseID was industrialized following the SynEx project.
However, the function of “smart “ links is of vital importance to nursing when working with standard care plans prepared according to the latest state of the art knowledge regarding standards for best nursing practices.
Presently, all linkages must be made by the users either while entering chains of problems, goals and interventions or after having entered problems, goals and interventions separatly.
It deserves mentioning, finally, that from a data point of view objectives were more than met.
With regard to interventions the industrialised version of the patient record surpasses the prototype because the distinction between interventions and their defining activities has been introduced on the data level. This distinction is a common place in nursing.
On the functional level this distinction is reflected by both the terminology manager and the nursing process manager.
By means of the terminology manager it is possible to create a catalogue of defining activities in addition to a catalogue of interventions. Correspondingly, it is possible to select defining activities in relation to interventions when documenting nursing care of the individual by means of the nursing process manager.
SynEx meant for TelenurseID first and foremost participation in an integration effort where the problem-oriented patient record developed might be federated with other applications of the wider hospital environment. This objective has been reached but more important than that, is perhaps the fact, that this objective could be reached without having to give up the independent objectives pursued by TelenurseID as such. The overall conclusion to be drawn is therefore that the middle-ware approach exemplified by the DHE allows integration of a telematic application for nursing without loss of nursing ID-ENTITY.
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