Representing Nursing Interventions

Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

• Resolving to myriad de-coupled fragments
• With vanishingly little focus on:
  • Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, outcomes, protocols, care plans and status...
  • Elements and context + purpose of capture:  e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider, determine and resolve how clinical content and context are bound together and preserved in USCDI.  The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user.  Only the source EHR/HIT system can structure clinical content and context properly.  Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

Should clarify what is meant…

Should clarify what is meant by a nursing intervention and provide a definition and examples. If a request for vital signs is a nursing intervention then it will be hard to know when the request is fulfilled. if the code doesn't match it will be hard to manage the process from request to fulfillment

We are delighted to see the…

We are delighted to see the addition of Nursing content in the 2017 ISA and concur with all of the recommendations for use of LOINC and SNOMED CT.