Reply by author Dr. Linda Q. Thede

Reply by author to Kathleen M. Hunter's Letter to the EditorInformatics: The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves?

Dear Dr. Hunter:

I agree with Dr. Hunter that 'nurse informaticists are working very hard, and with success, to have nursing terminologies and nursing-relevant data incorporated into electronic information systems and informatics technical standards.' I did state that much work has already been done in this area, including the development of the Nursing Minimum Data Set and the standardized nursing terminologies. My point, however, is that this is not showing up in the clinical area. Currently there are only a small percentage of healthcare facilities that actually use any of these terminologies for nursing documentation. If the terminologies are not moved into the clinical areas, they remain only an academic exercise. A difficulty that I see is that most nurses have not yet realized the potential of aggregated data from an electronic system. Data itself is objective, but what is retrieved is subjective and dependent on what is in the system. Until we make clinical use of a standardized terminology that allows us to link nursing problems (diagnoses) with interventions with outcomes, there will be no retrieval of information that we can use to guide practice, provide better patient care, and make nursing visible. Given the current level of activity at the federal level to install electronic records with standardized terminologies, I am afraid that the window of time for nurses to recognize the value of their data and find a way to have it incorporated to provide the above benefits  is getting shorter and shorter.

Dr. Linda Q. Thede