Study of development and evaluation of a protocol for electronic data interchange in nursing field

在家庭保健中，共享患者信息对于护理的连续性和患者生命的早期稳定至关重要。护理所需的患者信息的电子数据交换可能有助于实现这些目标。因此，我们设计了一项研究，以实现护理领域的电子数据交换环境。在这项研究中，我们有两个主要的结果写在下面。1)我们开发了一套标准项目，用于医院和家庭医疗机构之间的电子护理数据交换。首先，我们对日本医学信息学协会护理摘要网络研究组创建的“护理摘要数据项集”进行了修改，其中包含389个条目。然后，我们确定并添加了一些其他项目，这些项目可能构成护士撰写的患者摘要。然后，为了使每个项目的粒度相等，我们将它们与“日本医疗记录信息交换标识符集（J-MIX）”的元素进行比较，并对它们进行细分。因此，我们开发了护理摘要数据项目集（NDIS），该数据集由941个项目组成。2)通过在系统上实现NDIS，证明了NDIS的可行性。为了在实际系统中使用NDIS，有必要对每个用例进行文档类型定义（DTD）。因此，我们参照三家医院现有的护理摘要，定义了DTD，并利用NDIS对其中的元素进行描述。根据自己创建的DTD，描述了一个护理出院总结样本，并在全国高校医院联用软件“医疗文献管理系统”上实现。利用该系统，以NDIS语言描述的XML格式在系统间实现护理出院摘要的电子化传输。

In home health care, sharing patient information is important for continuity of nursing care and early stabilization of patients' lives. Electronic data interchange of patient information needed for caring can potentially contribute to those goals. Thus we designed a study to materialize an environment of electronic data interchange in nursing field. In this study we had two main results written below.1) We developed a standard set of items for electronic nursing data interchange between hospitals and home healthcare facilities.Firstly, we modified 'Nursing Summary Data Items Set' which was created by the Japan Association for Medical Informatics Nursing Summary Network Study Group and included 389 items. Then we identified and added some other items that might comprise a patient summary written by nurses. And then, to make the granularity of each item equal, we compared them with elements of 'the Japanese Set of Identifiers for Medical Record Information Exchange (J-MIX)' and subdivided them. As a result, we developed the data set called Nursing Summary Data Item Set (NDIS), which consisted in 941 items.2) We showed feasibility of NDIS by implementing it on a system.In order to use NDIS in actual systems, it is necessary to make Document Type Definition (DTD) of each use case. Thus referring to existing nursing summaries used in three hospitals, we defined a DTD and described elements in it by NDIS. According as the DTD created by us, we described a sample of nursing discharge summary and implemented it on 'the Medical Document Management System', which developed as national university hospital joint-use software. Using this system, we electronically transferred the nursing discharge summary between systems with XML format described in NDIS.