| Description |
Nursing orders are used to communicate requests for nursing actions for patient care. A nursing order may contain requests to assess, care, teach, manage, and so forth, and may be simple or complex. While the Clinical Care Classification System (CCC) has a well-defined nursing action hierarchy in its framework that may be used to structure nursing orders (Saba, 2012), it is common for nursing orders documented in electronic health records (EHRs) to be in a free text format and not accessible to be used for automated processing. Standardization is essential to share, compare, and automate clinical data processing, including nursing orders. A standardized nursing order will enable further data processing and support interoperability. Interoperability in health information technology is about securely exchanging health information without special effort on the part of the user and enabling further use of information to be turned into meaningful information (HealthIT.gov, 2019; Lehne et al., 2019). For example, standardized nursing orders could be used to estimate patient acuity based on the effort of nursing tasks evident in nursing orders.Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) is a rapidly emerging standard for interoperability and a newly-required standard for representing clinical data (21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program, 2020). Th clinical models defined using FHIR support clinical data such as medication and laboratory orders, but no assessment has been performed to determine whether it works for nursing orders. Within FHIR, there is a resource for "orders" but the resource is not specific to nursing orders.One method for standardizing nursing orders is to perform information modeling and identify all the data elements required to represent a nursing order. Once the different parts of an order have been fleshed out, they can be used to post-coordinate concepts into a fully-specified nursing order (Matney et al., 2017). An information model is useful to represent the structure of semantics of the content in the electronic health record (EHR) in the form of formal specifications (Moreno-Conde et al., 2016). Use of an information model can benefit vocabulary creation and maintenance because specific attributes can reduce the need to create redundant concepts (Matney et al., 2003). Currently, nursing orders are represented in different ways across different standards, and there is no standard specification for nursing orders in FHIR. Therefore, our goal was to create an information model for nursing orders in order to exchange nursing orders using FHIR. To achieve this goal, the project has the following specific objectives: i.To identify the scope of data elements required to represent nursing orders based on existing standardsii.To validate the identified data elements against nursing orders present in the electronic health record, andiii.To align the final set of identified data elements to the FHIR order resource and assess gaps. |
