Welcome. I'm Connie White Delaney from the

University of Minnesota. I serve as Dean of the School of Nursing

and also had biomedical health informatics for the Academic Health

Center. And, what you'll discover in our time

together is my absolute passion for biomedical health informatics.

And I have focused most of my career on the topic we're going to be talking

about, which is standardization. A key element of infomatics and

essentially forms the foundation for all interoperability and exchange.

But this is my real passion for informatics.

You and I have the ultimate opportunity and empowered opportunity to ensure that

families, communities, and in fact all of us in the global community, are

represented within the electronic health records, electronic databases, in our

research, in their fullness. And what I mean by fullness is We can

have diagnostic data about patients and families and communities.

We can have demographic data, but what really matters to the people we serve, is

what they think about their patient experience.

Getting home being able to interact with their family, having appropriate support

systems, being a full part of their communities.

And if the time and when the time comes, transition into a natural supportive and

peaceful death. So my foundation and passion for

informatics and for the topic we are talking about standardization Is always

fundamentally grounded in the people we serve, and my family.

So, let's share some thoughts as we deal with this topic of standardization.

The first place I would like to start when we think about our healthcare system

and the electronic Foundation that you and I are helping to create is

represented by a large initiative in the United States entitled the Continuously

Learning Health System. Our vision for that system is that we

will learn from the system, it will support our learning, it will support our

patient care and from those learning's also we will improve the system.

So, the continuously learning health system as you see here will generate and

apply the very best evidence, the best practice.

For you and I, and, and in supporting healthcare choices and provider.

It will drive the process of new discoveries.

And that will be a very natural outgrowth of the care process.

Whether it be patient, families, or communities.

And most significantly, to us as well is. A system that ensures a continuous

process of innovation, quality safety, and assuring value and healthcare.

You see a quick picture that captures all the elements at a very high level that

contribute to create a continuously learning health system.

You'll notice. That policy and technical infrastructure

are the core foundation as is privacy and security.

And an area that you and I spend a lot of our time on is how do we determine the

meaningful use and support the meaningful use of health infromation technology.

So, standardization comes in, in all three of these levels.

The continuously learning health system in the United States is supported by a

clearly defined Federal health IT strategic plan.

This is the plan for 2011 to 15. And you see the pattern of thought,

better technology, better information. And therefore we have transformed

healthcare. There are five fundamental goals.

We'll start with number one. Achieving adoption and information

exchange through the meaningful use of information technology.

And then you can follow the goals two through five that build upon this

fundamental information infrastructure. It's this fundamental infrastructure that

you and I are talking about at this time. And ultimately it empowers people through

IT to improve their health and to improve the healthcare system.

And then, helping us acheive a rapidly learning and technologically advanced

Information system and learning health care system.

So let's take a look at some fundamental concepts that relate to standardization.

A standardization that assures that we can exchange data information and

knowledge. I'm going to focus my comments on the

nursing minimum data set, the nursing management minimum data set, and an

international initiative, the international nursing minimum data set.

I'm simply using nursing as an example of essential data.

There are many other examples related to medicine in the other healthcare

professionals, and other providers. I'm focusing on nursing, we have one of

the most advanced and local to internationally articulated essential

data set works in the world. And again, the fundamental purpose of any

of this work in nursing minimum data set or essential data, is always grounded in

having the ability to most fully, deeply represent our patient's families and

communities. The decisions they make.

The decisions that providers make and the full experience of health care delivery,

meeting our health goals, safety goals, and of course, cost and efficiency goals.

So let's take a look at each one of these minimum data sets.

Again, the three that I'm going to focus on are focused on nursing simply as

exemplars. They include the US Nursing Minimum Data

Set, the Management Minimum Data Set, and the International Nursing Minimum Data

Set. Let's look first at the purpose of the

essential minimum data sets. Of course, they are designed to meet

information needs of multiple users, whether that be the provider, the

patient's families, pairs, policy makers. They are intended to be minimum, core,

essential data that captures the, care experience, the care delivery.

And minimum data sets enable the collection, the management.

manipulation and communication of data for many many purposes.

Of course those purposes relate back to the information needs of multiple users.

So let's look at the US Nursing Minimum Data Set.

That data set was actually derived in the 1980s.

One of the most famous developers associated with the US Nursing Minimum

Data Set is Harriet Orley. The data set consists of 16 elements.

They're organized into three large categories, and you're going to see a

similarity as we progress through the review of these three minimum data sets.

The first is nursing care elements for every patient, family and community that

we care for it's essential that we capture the nursing diagnosis.

And yes, that is different than the medical diagnosis, nursing interventions

nursing outcomes and something called the intensity of nursing care.

You and I can think about that as the resource related to people and time

required to deliver this nursing care. It also contains a second category of

essential data that we need to know about each patient, family, or community we

serve. For patients, personal identification,

date of birth, gender, sex, race and ethnicity, and the residence.

And then the service elements, some information about where the care was

provided. The facility or agency number, unique

health record. The unique number of the principle

registered nurse provider, when the care started, when it ended, what happened to

the patient or client, did they die, did they go transfer to skilled care, were

they able to go home? Who is the expected payer of the bill?

Many of these elements have been collected in the United States for 50, 60

years under something called the Uniform hospital discharge data set.

Why I highlight the UHDDS data collection is for those of you interested in

studying healthcare delivery and transformation over time.

This represents humongous data set that would support your scholarship.

Standardization - Part 1

Interprofessional Healthcare Informatics

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