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Easing the way for the electronic health record


Sixteen years after the Institute of Medicine called for implementation of the computerized patient health record, the healthcare industry is still debating exactly what that record is, how to implement it, and when.

Several terms have been used to define electronic patient records. Today, the most commonly used terms are electronic health record (EHR) and electronic medical record (EMR). Others include medical record and personal health record. Their definitions overlap somewhat, and the terms sometimes are used interchangeably. But they shouldn’t be, because they’re different entities.

• The medical record is the paper chart we’re used to. Usually, it’s maintained in multiples; commonly, it’s incomplete. And because it frequently includes handwritten illegible notes and nonstandard abbreviations, it can lead to medical errors. This is what we’re trying to move away from.
• The personal health record is medical information that a patient (or his or her caregiver) holds on to. It can be a paper record, an electronic record, or a combination. Ideally, everyone should build and maintain their own complete personal health record, including information their physicians may lack, such as exercise routines, dietary habits, herbal or nonprescription medications, and home test results.
• The EHR (on an individual level) comprises all of the patient’s medical information from all sources. Ideally, it’s accessible from any location by any sanctioned provider and contains information that’s current and updated continuously. The EHR also allows data collection for other uses, such as quality improvement, outcome reporting, resource management, and public health communicable disease surveillance.
• The EMR is a combination of the data in the paper chart and the personal health record—but in electronic form. Ideally, it makes patient health data available where needed, both by people and computers. Typically, one provider (a physician or healthcare facility) creates and maintains the EMR, but other sources may populate it.

No budget, no standards—no EHR
Because of financial issues and lack of standards, no country has implemented an operational national EHR. One study estimates that creating one in the United States within 5 years would require $156 billion in capital investment, plus $48 billion in annual operating costs.

As for standards, without them there can be no EHR—at least not one that operates at a level higher than the individual healthcare system. But as pressure mounts to develop a national EHR, we’re seeing an increasing urgency to create and adopt the standards needed to support it.

Now is the perfect time for the nursing profession to step up and develop standards. Fortunately, that’s exactly what’s happening.

Establishing nursing standards
Globally, the two most widely accepted standards used by the nursing profession are:

• International Classification for Nursing Practice (ICNP®) from the International Council of Nurses (ICN)
• SNOMED CT® (Systematized Nomenclature of Medicine Clinical Terms) from the College of American Pathologists.
ICNP is a nursing-specific terminology, whereas SNOMED CT is both a terminology and a platform for translating different terminologies. Both play critical roles in making the EHR a reality and ensuring nursing’s visibility within the EHR.

ICNP: A unified nursing language system
ICN defines ICNP as “a unified nursing language system that provides terminology for nurses to document their practice. It provides an international standard to facilitate description and comparison of data across specialties, health delivery settings, client populations, geographic regions, and languages.”

ICNP elements include nursing phenomena (diagnoses), actions, and outcomes. ICNP can serve as the standard for countries that lack one, or as a framework for development. For countries that already have their own standard, ICNP can serve as a bridge to the rest of the world.

SNOMED CT: An integrated platform
SNOMED CT maps healthcare concepts from various classification and standard systems to a common terminology that includes nursing diagnoses, interventions, and nurse-sensitive patient outcomes. It serves as a common framework for translating terminologies recognized by the American Nurses Association. SNOMED concepts and relationships represent clinical knowledge across the scope of nursing practice.

Perfecting the EHR through practice
The key—and the next hurdle—is putting ICNP and SNOMED CT standards into practice. Standards can be incorporated into practice in three ways—as specialty-specific ICNP catalogs, as an international mapping tool, and within the clinical information system.

Specialty-specific ICNP catalogs
A huge, dynamic terminology, ICNP is enhanced by local, regional, national, and international participation and use in practice. To promote such use, ICN is developing catalogs, or nursing data subsets, for specified health concerns. These catalogs subdivide the ICNP database into smaller groups of nursing diagnoses, interventions, and outcomes for selected nursing specialties, practice areas, and patient conditions.International mapping tool
An effort is underway to coordinate ICNP and SNOMED. ICNP catalog concepts will be represented using codes. SNOMED CT has characteristics that support mapping to other terminologies as well as synonyms that make it useful for recording clinical care. Thus, SNOMED CT–based organizations can use it to represent ICNP catalog concepts in clinical information systems.

Recently, representatives from Australia, Denmark, Lithuania, New Zealand, and the United Kingdom met with the College of American Pathologists to discuss creating a standards development organization to maintain and promote SNOMED CT. Their goal: to create an international standards organization that will enable countries and national authorities to take a leading role in developing, owning, and maintaining SNOMED CT. This is the first opportunity to establish global healthcare terminology standards—and, correspondingly, global data.

Clinical information systems
In an increasingly automated and global healthcare environment, getting ICNP into practice means getting it into the clinical information systems nurses use. Currently, business factors drive vendors’ and suppliers’ implementation efforts: Where a demand for ICNP exists, they seek to supply it.

The scope of implementation depends on the level at which the clinical information system operates—from individual stand-alone hospitals to national healthcare systems. But the process is underway, with major vendors and suppliers represented in collaborative committees.

Recent developments

Though it may seem like a slow process, we’ve made progress on the EHR. Here are some recent developments.

Progress in technology
The Department of Health and Human Services has designated its first recognized certification body—the Certification Commission for Healthcare Information Technology (CCHIT). CCHIT will evaluate information technology products to ensure they meet baseline requirements for functionality, interoperability, and security. Because the CCHIT seal of approval will certify a product’s technical capabilities, it should accelerate information technology adoption in health care. Also, by providing certification for interoperability, the CCHIT stamp will allow vendors and suppliers to donate EHR software, technology, and training. This will further spur adoption of information technology.

Progress in adoption
U.S. healthcare is far behind in adopting new systems that can improve patient care and reduce clinical errors. Part of the problem is lack of information and lack of a standard definition of the EHR. However, federal initiatives to ensure deployment of a national EHR by 2014 will force resolution of these issues. These initiatives also will necessitate transformation of nursing practice and education.

Recognizing this, a group of nurses and nurse advocates established the TIGER (Technology Informatics Guiding Educational Reform) initiative in 2005. In November 2006, they held a national summit to articulate a vision and create an action plan to enable nurses to use informatics in practice and education to provide safe, high-quality care. Participants developed a 10-year vision and action plan that includes support for a personal health record for everyone in the United States.

Progress in testing
In Hawaii, two hospitals and three clinics will get state-of-the-art EHR technology under a program funded by the U.S. Department of Defense. The 18-month study, which will serve as a test, is aimed at bringing all 12 state hospitals fully into the electronic age with respect to health records. The long-term goal is to allow updating of medical records wherever patients receive care and to make that data available to the next physician, wherever the patient seeks care.

What the EHR means to nursing
The EHR is the future—not just of health care but of nursing. The nursing profession needs data captured by the EHR for evidence-based practice, which in turn is crucial to the continuing viability of the profession. The automation that the EHR provides will streamline the work flow and reduce errors.

The EHR will unequivocally establish nursing’s role and value in the healthcare process and its contribution to high-quality outcomes. If nursing is absent from the EHR, it will be absent from public policy and the patient.

To make sure this doesn’t happen, nursing must define—and be defined by—nursing-established standards. The hesitancy of the healthcare industry to implement the EHR may well provide the breathing room the nursing profession needs.

Selected references
Blumenthal D, DesRoches C, Donelan K, et al. Health Information Technology in the United States: The Information Base for Progress. Washington, DC: Robert Wood Johnson Foundation; 2006. Available at: Accessed December 2, 2006.

Charette R. Dying for data. IEEE Spectrum Online. October 2006. Available at: Accessed December 29, 2006.

Kaushal R, Blumenthal D, Poon E, et al. The costs of a national health information network. Ann Intern Med. 2005;143:165-173. Available at: Accessed December 22, 2006.

Pinkerton K. History of electronic medical records. Available at: Accessed December 1, 2006.

For a complete list of selected references, see the selected references for February 2007.

Roy L. Simpson, RN, C, CCMA, FNAP, FAAN, is Vice President of Nursing Informatics at Cerner Corporation in Kansas City, Mo., and Co-Chair of the Expert Panel on Nursing Informatics of the American Academy of Nursing.

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