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DOI: 10.4338/ACI-2010-06-CR-0035
Meaningful Use of a Standardized Terminology to Support the Electronic Health Record in New Zealand
Correspondence to:
Publication History
received:
16 June 2010
accepted:
25 September 2010
Publication Date:
16 December 2017 (online)
Summary
Meaningful use is a multidimensional concept that incorporates complex processes; workflow; interoperability; decision support; performance evaluation; and quality improvement. Meaningful use is congruent with the overall vision for information management in New Zealand. Health practitioners interface with patient information at many levels, and are pivotal to meaningful use at the interface between service providers, patients, and the electronic health record. Advancing towards meaningful use depends on implementing a meaningful interface terminology within the electronic health record. The Omaha System is an interface terminology that is integrated within Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT®), and has the capacity to disseminate and capture information at the point of care because its codes are simple defined terms. Two community nursing and allied health providers who are considering using the Omaha System in clinical systems for gathering intervention and outcomes data within the personal EHR include Nurse Maude and the Royal New Zealand Plunket Society. Help4U is investigating using the Omaha System as a way to standardise health terminology for consumer use. The Omaha System is also a good fit with the Midwifery and Maternity Providers Organisation (MMPO) existing clinical information system to describe and capture data about interventions currently recorded as free text. As a country that promotes access to affordable primary care and free hospital care, within an environment constrained by resource limitations, maximizing the use of data is key to demonstrating health outcomes for the population.
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Keywords
Electronic health records and systems - clinical documentation and communication - clinical data management - standards - evaluation
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Conflicts of interest
The authors are informatics specialists with expertise in use of the Omaha System in education and research. All authors declare no conflict of interest in the preparation of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the authors’ employers.
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References
- 1 Markle Foundation [Internet].. Achieving the health IT objectives of American Recovery and Rein-vestment Act: A framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR. [updated 2010 Apr; cited 2010 Oct 14]. Available from: http://markle.org/downloadable_assets/20090430_meaningful_use.pdf.
- 2 Mosquera M [Internet].. Blumenthal puts quality reporting at apex of meaningful use. [updated 2009 Oct 15; cited 2010 Oct14]. Healthcare IT News; [about 2 screens]. Available from: http://www.govhealthit.com/newsitem.aspx?nid=72216
- 3 US Department of Health and Human Services [Internet].. Electronic Health Records and Meaningful Use. [updated 2010 Jul 26; cited 2010 Oct14]. Office of the National Coordinator for Health Information Technology; [about 2 screens]. Available from: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&parentname=CommunityPage&parentid=1&mode=2
- 4 American Nurses Association [Internet].. ANA Recognized Terminologies and Data Element Sets. [updated 2006 May 11; cited 2010 Oct14]. Nursing World; [about 1 screen]. Available from: http://www.nursingworld.org/npii/terminologies.htm
- 5 Lundberg C, Warren JJ, Brokel JM. et al. Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online J Nurs Inform [Internet]. 2008; 12 (02) 1-19. Available from: http:ojni.org/12_2/lundberg.pdf
- 6 Westra BL, Delaney CW, Konicek D, Keenan G. Nursing standards to support the electronic health record. Nurs Outlook. 2008; 56 (05) 258-266.
- 7 Monsen KA, Banerjee A, Das P. Discovering client and intervention patterns in home visiting data. West J Nurs Res. 2010 Aug 11. [Epub ahead of print].
- 8 Monsen KA, Martin KS, Christensen JR, Westra BL. Omaha System data: methods for research and program evaluation. St Heal T 2009; 146: 783-784.
- 9 Monsen KA, Westra BL, Yu F, Ramadoss VK, Kerr MJ. Data management for intervention effectiveness research: Comparing deductive and inductive approaches. Res Nurs Health. 2009; 32 (06) 647-656.
- 10 Martin KS. The Omaha System: A key to practice, documentation, and information management, 2nd ed. Omaha (NE): Health Connections Press; 2005
- 11 Statistics New Zealand [Internet].. QuickStats of 2006 census data. [cited 2010 Oct 14]. Available from: http://www.stats.govt.nz/Census/2006CensusHomePage/QuickStats.aspx
- 12 Connolly M, Boyd M-A, Kenealy T, Moffitt A, Sheridan N, Kolbe J. [Internet]. Alleviating the burden of chronic conditions in New Zealand: The ABCC NZ Study Workbook 2010. [updated 2010 January; cited 2010 Oct14] Auckland: The University of Auckland and Freemason’s Unit of Geriatric Medicine. Available from: http://dhbrf.hrc.govt.nz/media/documents_abcc/ABCC_Study_Workbook_Final.pdf.
- 13 Ministry of Health.. Diabetes surveillance. Wellington, New Zealand: Ministry of Health; 2007
- 14 Ministry of Health.. The health and independence report 2008. Wellington, New Zealand: Ministry of Health; 2008
- 15 Ministry of Health.. New Zealand health and disability sector overview. Wellington, New Zealand: Ministry of Health; 2003
- 16 Davey JA, Gee S. Life at 85 plus: A statistical review. Wellington, New Zealand: New Zealand Institute for Research on Ageing; 2002
- 17 Ministry of Health.. The New Zealand Health Strategy. Wellington, New Zealand: Ministry of Health; 2000
- 18 New Zealand Health Information Service.. Guide to the national health information collections. Wellington, New Zealand: Ministry of Health; 2006
- 19 New Zealand Health Information Service [Internet].. New Zealand SNOMED CT® National Release Cent-re. [updated 2010 Jan 22; cited 2010 Oct 14]. Available from: http://www.nzhis.govt.nz/moh.nsf/pagesns/497
- 20 Health Information Strategy Steering Committee.. Health Information Strategy for New Zealand. Wellington, New Zealand: Ministry of Health; 2005
- 21 Accident Compensation Corporation (ACC) [Internet].. READ codes. [updated 2010 Sept 3; cited 2010 Oct14] Available: from http://www.acc.co.nz/for-providers/lodge-and-manage-claims/prv00037
- 22 World Health Organization [Internet].. International Classification of Diseases. [updated 2010; cited 2010 Oct 14]. Available from: http://www.who.int/classifications/icd/en
- 23 Health Workforce New Zealand [Internet].. Current status of the national regulated nursing workforce. [updated 2009; cited 2010 Oct 14]. Available from: http://healthworkforce.govt.nz/sites/all/files/current-state-nursing.pdf
- 24 Nursing and Midwifery Workforce Strategy Group [Internet].. Nursing workforce strategy. [updated 2006; cited 2010 Oct 14]. Available from http://www.dhbnz.org.nz/includes/download.aspx?ID=25740
- 25 Honey M, North N. Supporting workforce development of nurses: Exploiting the synergies between technology in education and practice. Health Care and Informatics Review Online Journal [Internet]. 2009 Feb 1-7. Available from: http://www.hinz.org.nz/journal-pdf/1003
- 26 Martin KS, Norris J, Leak GK. Psychometric analysis of the Problem Rating Scale for Outcomes. Outcomes Management for Nursing Practice. 1999; 3 (01) 20-25.
- 27 Martin KS, Scheet NJ. The Omaha System: Applications for community health nursing. Philadelphia: Saunders; 1992
- 28 Omaha System [Internet].. The Omaha System: Solving the clinical data-information puzzle. [updated 2010 Oct 1; cited 2010 Oct 14]. Available from: http://omahasystem.org.
- 29 Martin KS, Monsen KA, Bowles KH. The Omaha System: Meaningful use examples from practice, education, and research. CIN - Comput Inform Nu. In press.
- 30 Wilson SK [Internet].. Development of a personal digital assistant (PDA) as point-of-care technology in nursing education. PDA Cortex: The Journal of Mobile Informatics. [updated 2004; cited 2010 Oct 14]. Available from: http://www.pdacortex.com/pda_nursing_education.htm
- 31 Wilson SK, Duke J. Locating nursing classification schemes within health information strategies for New Zealand, MEDINFO 2007 Proceedings of the 12th World Congress on Health (Medical) Informatics. edited by K. Kuhn et al. Netherlands: IOS Press; 2007. Part 2 1144-1148.
- 32 Changing the way nurses and allied health professionals document and communicate care in community clinical practice: A community care clinical data set [Internet]. Nurse Maude, McGrath B [updated 2009; cited 2010 Oct 14] Available from: http://www.hinz.org.nz/uploads/file/2009conference/P11_McGrath.pdf
- 33 Monsen KA, Fitzsimmons LL, Lescenski BA, Lytton AB, Schwichtenberg LD, Martin KS. A public health nursing informatics data-and-practice quality project. CIN - Comput Inform Nu. 2006; 24 (03) 152-158.
Correspondence to:
-
References
- 1 Markle Foundation [Internet].. Achieving the health IT objectives of American Recovery and Rein-vestment Act: A framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR. [updated 2010 Apr; cited 2010 Oct 14]. Available from: http://markle.org/downloadable_assets/20090430_meaningful_use.pdf.
- 2 Mosquera M [Internet].. Blumenthal puts quality reporting at apex of meaningful use. [updated 2009 Oct 15; cited 2010 Oct14]. Healthcare IT News; [about 2 screens]. Available from: http://www.govhealthit.com/newsitem.aspx?nid=72216
- 3 US Department of Health and Human Services [Internet].. Electronic Health Records and Meaningful Use. [updated 2010 Jul 26; cited 2010 Oct14]. Office of the National Coordinator for Health Information Technology; [about 2 screens]. Available from: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&parentname=CommunityPage&parentid=1&mode=2
- 4 American Nurses Association [Internet].. ANA Recognized Terminologies and Data Element Sets. [updated 2006 May 11; cited 2010 Oct14]. Nursing World; [about 1 screen]. Available from: http://www.nursingworld.org/npii/terminologies.htm
- 5 Lundberg C, Warren JJ, Brokel JM. et al. Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online J Nurs Inform [Internet]. 2008; 12 (02) 1-19. Available from: http:ojni.org/12_2/lundberg.pdf
- 6 Westra BL, Delaney CW, Konicek D, Keenan G. Nursing standards to support the electronic health record. Nurs Outlook. 2008; 56 (05) 258-266.
- 7 Monsen KA, Banerjee A, Das P. Discovering client and intervention patterns in home visiting data. West J Nurs Res. 2010 Aug 11. [Epub ahead of print].
- 8 Monsen KA, Martin KS, Christensen JR, Westra BL. Omaha System data: methods for research and program evaluation. St Heal T 2009; 146: 783-784.
- 9 Monsen KA, Westra BL, Yu F, Ramadoss VK, Kerr MJ. Data management for intervention effectiveness research: Comparing deductive and inductive approaches. Res Nurs Health. 2009; 32 (06) 647-656.
- 10 Martin KS. The Omaha System: A key to practice, documentation, and information management, 2nd ed. Omaha (NE): Health Connections Press; 2005
- 11 Statistics New Zealand [Internet].. QuickStats of 2006 census data. [cited 2010 Oct 14]. Available from: http://www.stats.govt.nz/Census/2006CensusHomePage/QuickStats.aspx
- 12 Connolly M, Boyd M-A, Kenealy T, Moffitt A, Sheridan N, Kolbe J. [Internet]. Alleviating the burden of chronic conditions in New Zealand: The ABCC NZ Study Workbook 2010. [updated 2010 January; cited 2010 Oct14] Auckland: The University of Auckland and Freemason’s Unit of Geriatric Medicine. Available from: http://dhbrf.hrc.govt.nz/media/documents_abcc/ABCC_Study_Workbook_Final.pdf.
- 13 Ministry of Health.. Diabetes surveillance. Wellington, New Zealand: Ministry of Health; 2007
- 14 Ministry of Health.. The health and independence report 2008. Wellington, New Zealand: Ministry of Health; 2008
- 15 Ministry of Health.. New Zealand health and disability sector overview. Wellington, New Zealand: Ministry of Health; 2003
- 16 Davey JA, Gee S. Life at 85 plus: A statistical review. Wellington, New Zealand: New Zealand Institute for Research on Ageing; 2002
- 17 Ministry of Health.. The New Zealand Health Strategy. Wellington, New Zealand: Ministry of Health; 2000
- 18 New Zealand Health Information Service.. Guide to the national health information collections. Wellington, New Zealand: Ministry of Health; 2006
- 19 New Zealand Health Information Service [Internet].. New Zealand SNOMED CT® National Release Cent-re. [updated 2010 Jan 22; cited 2010 Oct 14]. Available from: http://www.nzhis.govt.nz/moh.nsf/pagesns/497
- 20 Health Information Strategy Steering Committee.. Health Information Strategy for New Zealand. Wellington, New Zealand: Ministry of Health; 2005
- 21 Accident Compensation Corporation (ACC) [Internet].. READ codes. [updated 2010 Sept 3; cited 2010 Oct14] Available: from http://www.acc.co.nz/for-providers/lodge-and-manage-claims/prv00037
- 22 World Health Organization [Internet].. International Classification of Diseases. [updated 2010; cited 2010 Oct 14]. Available from: http://www.who.int/classifications/icd/en
- 23 Health Workforce New Zealand [Internet].. Current status of the national regulated nursing workforce. [updated 2009; cited 2010 Oct 14]. Available from: http://healthworkforce.govt.nz/sites/all/files/current-state-nursing.pdf
- 24 Nursing and Midwifery Workforce Strategy Group [Internet].. Nursing workforce strategy. [updated 2006; cited 2010 Oct 14]. Available from http://www.dhbnz.org.nz/includes/download.aspx?ID=25740
- 25 Honey M, North N. Supporting workforce development of nurses: Exploiting the synergies between technology in education and practice. Health Care and Informatics Review Online Journal [Internet]. 2009 Feb 1-7. Available from: http://www.hinz.org.nz/journal-pdf/1003
- 26 Martin KS, Norris J, Leak GK. Psychometric analysis of the Problem Rating Scale for Outcomes. Outcomes Management for Nursing Practice. 1999; 3 (01) 20-25.
- 27 Martin KS, Scheet NJ. The Omaha System: Applications for community health nursing. Philadelphia: Saunders; 1992
- 28 Omaha System [Internet].. The Omaha System: Solving the clinical data-information puzzle. [updated 2010 Oct 1; cited 2010 Oct 14]. Available from: http://omahasystem.org.
- 29 Martin KS, Monsen KA, Bowles KH. The Omaha System: Meaningful use examples from practice, education, and research. CIN - Comput Inform Nu. In press.
- 30 Wilson SK [Internet].. Development of a personal digital assistant (PDA) as point-of-care technology in nursing education. PDA Cortex: The Journal of Mobile Informatics. [updated 2004; cited 2010 Oct 14]. Available from: http://www.pdacortex.com/pda_nursing_education.htm
- 31 Wilson SK, Duke J. Locating nursing classification schemes within health information strategies for New Zealand, MEDINFO 2007 Proceedings of the 12th World Congress on Health (Medical) Informatics. edited by K. Kuhn et al. Netherlands: IOS Press; 2007. Part 2 1144-1148.
- 32 Changing the way nurses and allied health professionals document and communicate care in community clinical practice: A community care clinical data set [Internet]. Nurse Maude, McGrath B [updated 2009; cited 2010 Oct 14] Available from: http://www.hinz.org.nz/uploads/file/2009conference/P11_McGrath.pdf
- 33 Monsen KA, Fitzsimmons LL, Lescenski BA, Lytton AB, Schwichtenberg LD, Martin KS. A public health nursing informatics data-and-practice quality project. CIN - Comput Inform Nu. 2006; 24 (03) 152-158.