Standards for nursing content of electronic records Anne Casey Information Standards Adviser Royal College of Nursing, UK Harnessing technology to promote healthcare efficiency and social inclusion

Advancing the digital agenda for effective and efficient health care u Developing standards for nursing content u Other standards - gaps u Clinical governance of standards u ‘Patient-centred’ - a nursing view

Nursing content of electronic records what is written or entered into the (multi-disciplinary) patient record that reflects the nursing contribution to care and outcomes of that care. Content must: u support effective clinical judgements, decisions, care and communication u reflect core nursing values such as patient focus, partnership working, confidentiality, respect and choice u provide accurate data for commissioning, workforce planning, performance monitoring, quality improvement, and research.

EVIDENCEEXPERTS PRACTICE STANDARDS Including documentation and audit data requirements Content of systems based on practice standards Represented using standardised terminology Improved communication Support for clinical decision making Support for evidence based practice Data for audit, research and management

Minimum acceptable documented neurological observations: Glasgow coma score; limb movements; pupil size and reactivity; blood oxygen saturation; respiratory rate; heart rate; blood pressure; temperature. Government IT programmes Health informatics standards organisations Terminology and classification developers Academic Institutes and Industry partners

Professional organisations u Leadership role – Getting ehealth on the agenda and prioritised u Working with guideline / practice standard developers u Support for ‘technical’ aspects of professional standards: skills, repository management, glossary management u Standards for using ICT in practice

Standards Gap Process standards: u safety u human factors ?

Clinical governance of ehealth standards National level: Health service & Government standards Regulator, National Association & specialist groups International level: ISO TC215, HL7, WHO, IHTSDO ICN & international specialist groups Regional level: Europe CEN TC251 EFN & European specialist groups With support from Informatics specialist groups IMIA-NI, ACENDIO, EFMI-NI

European Federation of Nurses Associations Position statement on ehealth October 2009 ehealth …new, improved, and efficient health era based on technologies that can be safely implemented Nursing: major stakeholder; should be closely involved Safety risk management and patient centeredness throughout the development lifecycle, including use and discontinuation of technologies ehealth developments –must not worsen health inequalities –should support and not hinder the work of clinicians - usability and human factors standards and development approaches.

Clinical stakeholder participation in the work of ISO TC 215 ISO Technical Report 11487:2008 u ‘national member bodies to report on measures being taken to engage and facilitate the participation of clinical stakeholders at the domestic level as a basis for further action and to identify models of good practice that other members could adopt’. Issues: –National representation model: liaison role only (cf IHTSDO) –Volunteers and busy clinicians - funding support? –Routes in to the work and time taken to become expert –How are health informatics standards addressed in clinical career paths, starting with undergraduate curricula?

‘Patient-centred’? u information centred on the patient u access allowed by provider u patient has control u other models ?? one model does not fit all

Negotiated partnership to achieve personal health goals (ICT) Support for informed decision- making and self management - to the extent preferred / able Person is not disadvantaged if she/he cannot or chooses not to make decisions, use technology, give own injections….

u u