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

在家庭医疗中，共享患者信息对于护理的连续性和患者生活的早期稳定具有重要意义。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。本研究的主要成果如下：1)开发了医院与家庭医疗机构之间电子护理数据交换的标准条目集。首先，对日本医学信息学协会护理摘要网络研究小组创建的包含389个条目的《护理摘要数据条目集》进行了修改。然后，我们确定并添加了一些其他项目，这些项目可能包括护士撰写的患者摘要。然后，为了使每一项的粒度相等，我们将它们与《日本病历信息交换标识集(J-MIX)》中的元素进行比较并对其进行细分。在此基础上，开发了护理总结数据项集(NDIS)，包括941个项目。2)通过在系统上的实现，验证了NDIS的可行性，为了在实际系统中使用NDIS，需要对每个用例进行文档类型定义(DTD)。因此，参考三家医院现有的护理总结，我们定义了DTD，并用NDIS描述了其中的要素。根据我们创建的DTD，我们描述了一个护理出院总结的样本，并在国家大学医院联合使用软件开发的医疗文档管理系统上实现了它。使用该系统，我们以NDIS中描述的XML格式在系统之间电子传输护理出院总结。

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.