Nursing standards to support the electronic health record

Abstract

Quality and low cost health care that is free of medical mistakes requires continuity of person-centric healthcare information across the life span and healthcare settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive Order called for a National Health Information Network and the widespread adoption of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to support nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development.