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• An active allergy list maintenance • Smoking status • E-prescriptions • Incorporation of clinical lab data into EHR In addition to the major core objectives, eligible providers


and eligible hospitals must choose additional menu measures, as well as report clinical quality measures.8


More detail about


the clinical quality measures is available at http://www.cms.gov/ Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ ClinicalQualityMeasures.html. Figuring out the best way to measure healthcare quality is


continually evolving, requiring healthcare leaders and task forces to maintain an open dialogue to arrive at a consensus. Nurses must participate in this dialogue as the outcomes directly shape policy-related decisions that affect nurses and the care they provide to patients. Success of implementing themeaningful use incentive programdepends on the entire care team.But nursing input regard- ing effective use is key as nurses are the largest group ofEHRusers. Nurse leaders and development teams are using their influence to drive meaningful use in the direction of safe, patient-centered care that highlights the value of skilled nursing care.9


Informatics nurses


are often the experts who become involved in designing system requirements andworkflows that nurses and other clinicians com- plete as they provide and document care to meet particular quality measures. Nursing input ensures that clinical workflows using EHRsmakes sense froma practical and patient safety perspective.


Not just about data For data to be useful, it must be structured and coded such that information can be exchanged as well as interpreted. This ability to exchange and use data at their highest level is called “semantic interoperability.” Semantic interoperability incorporates both the structuring and coding of data, including standardized terminology use, so that information can be shared across technology systems. It is through semantic interoperability that otherwise unrelated systems, such asEHRmedical devices and mobile technologies, can share and use data to improve healthcare quality, safety and cost-effectiveness. Incorporating nursing data into EHR coding ensures that


nursing documentation has a voice in healthcare documentation. If the nursing voice is silenced by lack of relevant healthcare data, institutional decisions and reimbursements will fail to reflect the necessity of skilled nursing care.10


The development


of standardized nursing terminologies is onemajor challenge in the ongoing effort to ensuring semantic interoperability. There are 12 terminologies recognized by the AmericanNurses Associ- ation, includingNANDA(formerly theNorth AmericanNursing Diagnosis Association), Systematized Nomenclature of Medi- cine-Clinical Terms (SNOMED-CT) and the Omaha System.11 Agreeing upon standard terminologies that can be integrated consistently across systems and alongwith medical terminologies such as SNOMED-CT is more complex than it may seem. For instance, consider two nursing diagnoses: risk for injury and risk for trauma. In nursing, these concepts have different meanings and one can be a precursor for another (trauma can be a form of injury and injury can be a type of trauma). In SNOMED-CT, trauma (meaning physical injury) and injury are considered syn- onymous concepts.12


Reaching a consensus on how to approach 22 JANUARY/FEBRUARY 2016 • MIDWEST


these semantic differences is a challenge, but also necessary for ensuring interoperability. Progress in the development and use of standard semantic terminologies has been slowacross the board.


How interoperability affects nursing Clinical decision support systems:Clinical decision support (CDS) is a sophisticated component of health information technology. CDS gives healthcare providers and patients information that is both person specific and timely. This information is filtered such that the recipient is given only pertinent and relevant data for clinical decision-making. Examples of CDS include: • Computerized alerts and reminders • Clinical guidelines • Condition-specific order sets • Focused patient data reports and summaries • Documentation templates • Diagnostic support • Contextually relevant reference information13 An example of the use ofCDS to improve patient care is the use


of practice alerts to address the issue of hospital associated pressure ulcers,which cost the U.S. $3.2 billion each year.Aroot cause anal- ysis at Kaiser Permanente revealed that skin breakdown prevention could be enhanced by practice reminders that alert a nurse when documentationwas not current. Interventions such as thishave been successful in reducing the incidence of hospital-associated pressure ulcers, as well as other hospital-acquired conditions, such as falls and catheter-associated infections.Note that the use of technology to improve outcomesmustmeet certain goals. Technology needs to simplify the nurse’s workflow, support the nurse with knowledge and reduce tasks that are of little value to nursing care.14


With these


goals inmind, the EHRand other aspects ofHIE can simplify and improve nursing care, rather than increase its complexity. Personal health record: A personal health record (PHR) differs


from the EHR.While the EHR is a systemaccessed and updated by health providers, a PHR is used by an individual patient and can include information from a variety of providers. They may include elements such as patient contact information, family medical history, list of providers, diagnoses, medications and allergies, immunizations and labs.15 As the use of PHRgrows, considerations for a fully interoperable


PHRmust be taken into account. If a PHRis solely operated by the patient (known as a stand-alone PHR), there is a risk for missing or incomplete information, particularly if a patient views separate healthcare encounters as unrelated. For instance, a patient with heart disease presents to the ED complaining of chest pain, but fails to mention a recent cardiac catheterization. Fragmented information will reduce the value and usability of a PHR.However, if the PHR is built on an interoperable infrastructure, in which providers can help with maintenance and addition of important data, the PHR can be an invaluable tool that gives any clinician who cares for that patient a complete picture of the patient’smedical history. In 2010, theDepartment ofVeterans Affairs healthcare system


released theVABlue Button. TheVAis the largest integrated health- care system in the country, withmore than 300,000 employees, more than 80,000 of them nurses. The Blue Buttonwas designed to encourage patient engagement by providing patients with the ability to access personal health information. The functionality of


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