Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines

민열하,박현애,정은자,이현숙 대한의료정보학회 2013 Healthcare Informatics Research Vol.19 No.4

Objectives: The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. Methods: A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. Results: The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. Conclusions: An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.

Applicability of the ISO Reference Terminology Model for Nursing to the Detailed Clinical Models of Perinatal Care Nursing Assessments

민열하,박현애 대한의료정보학회 2011 Healthcare Informatics Research Vol.17 No.4

Objectives: The purpose of this study was to examine the applicability of the International Organization for Standardization (ISO) reference terminology model for nursing to describe the terminological value domain content regarding the entities and attributes of the detailed clinical models (DCMs) used for nursing assessments. Methods: The first author mapped 52 DCM entities and 45 DCM attributes used for perinatal care nursing assessments to semantic domains and their qualifiers to the ISO model. The mapping results of the entity and attribute concepts were classified into four categories: mapped to a semantic domain qualifier, mapped to a semantic domain, mapped to a broader semantic domain concept, and not mapped. The DCM mapping results were classified into three categories: fully mapped, partially mapped, and not mapped. The second author verified the mapping. Results: All of the entities and 53.3% of the attribute concepts of the DCMs were mapped to semantic domains or semantic domain qualifiers of the ISO model, 37.8% of the attributes were mapped to the broader semantic domain concept, and 8.9% of the attributes were not mapped. At the model level, 48.1% of the DCMs were fully mapped to semantic domains or semantic domain qualifiers of the ISO model, and 51.9% of the DCMs were partially mapped. Conclusions: The findings of this study demonstrate that the ISO reference terminology model for nursing is applicable in representing the DCM structure for perinatal care nursing assessment. However, more qualifiers of the Judgment semantic domain are required in order to clearly and fully represent all of the entities and attributes of the DCMs used for nursing assessment.

유방암 환자의 간호문제 아키타입 개발과 타당성 검증

민열하,박현애 대한의료정보학회 2009 Healthcare Informatics Research Vol.15 No.4

Objective: Archetypes as structured models of clinical content are considered to be the key broker between the reference models and terminology. This study developed and validated archetypes for nursing problems with breast cancer patients. Methods: Archetypes were developed with the focuses and characterizing categories to describe the nursing problems identified from the perioperative nursing records of breast cancer patients, a literature review and experts’ survey. The archetypes were validated by experts and applied to the clinical cases. Results: Forty seven focuses and 22 characterizing categories of nursing problems were identified. Forty five archetypes, except for the symptoms of URI and vital signs, could be grouped into 16 different types. The symptoms of URI and vital signs were modeled by a combination of other archetypes. The experts’ evaluation and application to clinical cases demonstrated the validity of the archetypes developed. Conclusion: Archetypes for nursing problems developed in this study can ensure interoperability and contribute to the exchange and sharing of the high quality structured data and information.

통증 간호사정을 위한 임상내용모델 개발

민열하 ( Yul Ha Min ),박현애 ( Hyeoun Ae Park ),이영지 ( Young Ji Lee ),김영란 ( Young Lan Kim ),이명경 ( Myung Kung Lee ) 서울대학교 간호과학연구소 2011 간호학의 지평 Vol.8 No.2

Purpose: The aim of this study was to develop and validate Detailed Clinical Models (DCMs) for pain assessment in nursing. Methods: First, we identified the entities of pain assessment from ICNP. We identified the attributes and values of the attributes to describe the entities in more detail by reviewing the literature. Data types and optionalities of the attributes were defined. Second, we modeled the DCMs by linking an entity and its corresponding attributes with values and by specifying the data types and optionalities of the attributes. Finally, the DCMs were validated by a group of domain experts using a content validity index. Results: In total, 19 DCMs with 11 attributes for pain assessment were developed. The experts` evaluations showed that the DCMs were valid enough to represent pain related information of nursing assessment. Conclusion: The DCMs developed in this study can be used in electronic nursing records. The DCMs for pain can ensure the semantic interoperability of pain related information in electronic nursing records.

국내 간호대학생의 자아탄력성 증진에 대한 통합적 고찰

서경산, 민열하, 이해영 청주대학교 보건의료과학연구소 2016 보건의료과학연구 Vol.5 No.1

Nursing student resilience is defined as the ability to successfully cope with the challenges and adversities in the academic and clinical settings using proper self-control. This study is to review and synthesize, systematically, the research dealing with resilience and factors influencing resilience in Korean nursing students. Study design is integrative review and eligible studies were identified by searching KoreaMed, KISS, RISS4U, and NSDL (google scholar) with key words of ‘nursing school student’ and ‘resilience’. Three researchers independently reviewed the studies. Twelve non-experimental studies were selected. Resilience was measured using two tools with scores ranging from 66 to 72 out of 100. Students perceived clinical practices and circumstances as adversity and expressed it as feeling insecure or stressful. Resilience was related to both internal factors (self-efficacy, competence, problem solving, stress coping, critical thinking, emotional intelligence, and communication skills) and external factors (family support and teaching effectiveness). Resilience was positively associated with academic adaptation, clinical practice satisfaction, major satisfaction, school satisfaction and professional identity. No literature was on resilience enhancing interventions or the evaluation of them. Further research is needed to examine the correlations, develop interventions that improve resilience and evaluate them based on theories.

Development of Detailed Clinical Models for Nursing Assessments and Nursing Interventions

박현애,민열하,김영란,이명경,이영지 대한의료정보학회 2011 Healthcare Informatics Research Vol.17 No.4

Objectives: The aim of this study was to develop and validate Detailed Clinical Models (DCMs) for nursing assessments and interventions. Methods: First, we identified the nursing assessment and nursing intervention entities. Second, we identified the attributes and the attribute values in order to describe the entities in more detail. The data type and optionality of the attributes were then defined. Third, the entities, attributes and value sets in the DCMs were mapped to the International Classification for Nursing Practice Version 2 concepts. Finally, the DCMs were validated by domain experts and applied to case reports. Results: In total 481 DCMs, 429 DCMs for nursing assessments and 52 DCMs for nursing interventions, were developed and validated. The DCMs developed in this study were found to be sufficiently comprehensive in representing the clinical concepts of nursing assessments and interventions. Conclusions: The DCMs developed in this study can be used in electronic nursing records. These DCMs can be used to ensure the semantic interoperability of the nursing information documented in electronic nursing records.

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

박현애,민열하,전은주,정은자 대한의료정보학회 2012 Healthcare Informatics Research Vol.18 No.2

Objectives: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. Methods: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. Results: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. Conclusions: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.

항호르몬요법을 받는 유방암 여성의 갱년기 증상과 연관 변인간의 분석

김영란,민열하 병원간호사회 2017 임상간호연구 Vol.23 No.1

Purpose: The purpose of this study was to identify the degree of menopause symptoms and associated factors in patients with breast cancer who were receiving hormone therapy. Methods: Data were collected with questionnaires from 150 patients with breast cancer who had been on hormone therapy at a hospital in Seoul. Data were analyzed with the t-test, ANOVA, and Pearson correlation coefficient to compare the degree of menopause symptoms by demographic, clinical and psychological factors. Results: The mean menopause symptoms score was 13.39±7.97. Most participants reported having hot flushes and sweating (75.3%), physical and mental exhaustion (82.7%) and sexual problems (64.7%). Menopause symptoms and depression were correlated with each other (p<.01). Somato-vegetative symptoms were different significantly by age, menopausal status at time of operation, occupation and tumor. Psychological symptoms were different significantly by marital status, operation type and chemotherapy. Urogenital symptoms were different significantly by prior history of cancer, occupation, operation type and radiation therapy. Conclusion: These findings can be used to provide tailored nursing interventions by identifying high risk groups for menopausal symptom among breast cancer patients receiving hormone therapy 연구목적: 본 연구는 항호르몬요법을 받고 있는 유방암 환자를 대상으로 갱년기 증상의 정도와 연관된 변인을 확인하기 위함이다. 연구방법: 서울의 일개병원에 내원하여 항호르몬요법을 받고 있는 유방암 환자 150명을 대상으로 자료수집을 시행하였다. 대상자의 일반적, 임상적 및 심리적 특성에 따른 갱년기 증상의 정도를 비교하기 위해 t-test, ANOVA, 상관관계분석을 이용하였다. 연구결과: 갱년기 증상의 평균 점수는 13.39±7.97 이었다. 대상자 중 다수에서 갱년기의 신체화, 심리적, 비뇨생식계 증상 중 안면홍조와 발한(75.3%), 신체적ㆍ심리적 피로감(82.7%), 성적 문제(64.7%)를 갖는 것으로 나타났다. 우울은 모든 갱년기 증상과 연관되어 있었으며(p< .01) 신체화 증상은 연령, 폐경여부, 직업유무, 종양특성에서, 심리적 증상은 결혼상태, 수술유형, 항암화학요법 여부에서, 비뇨생식기계 증상은 암의 기왕력, 직업유무, 수술유형, 방사선요법여부에 따라 차이가 있었다. 결론: 본 연구결과는 갱년기 증상의 고위험군을 선별함으로써 항호르몬요법을 받는 유방암 환자들에게 증상에 따른 맞춤화된 간호 중재를 제공하는 데 활용될 수 있다.

장애인을 위한 건강정보 웹사이트 개발

박현애,민열하,류동희,변용찬,김성희,윤상용 대한의료정보학회 2003 Healthcare Informatics Research Vol.9 No.2

The purpose of the study is to develop a Web-based health information service system for the disabled. To identify users' information needs, we conducted an online and offline survey of the disabled and their caregivers as well as welfare institutes' staff. Based on the user's information needs, a Web-site was developed. The Web-site was evaluated by users for their satisfaction with the Web-site and by experts for the quality of the site. Content of the Web-site includes information on rehabilitation, welfare, and diseases causing the disability, definition and classification of disability, prevention from disability, management of the disabled, and disability related policies. Besides this information, FAQ on the disabled, statistics, links to the disabled institutes and Web sites, risk factor appraisal tool, and aiding tools for the disabled are added. The Web site is a subsystem of the Healthguide. Users rated efficiency, convenience, and design of the site highly in their satisfaction rating. Staff at welfare institutes rated design, efficiency, and relevance of the site highly in their satisfaction rating. Experts rated easiness, reliability, clearness and appropriateness of the site highly in their site evaluation. It is expected that this Web-based health information service system for the disabled will contribute to the disabled's health promotion as well as provide a community for the disabled related researchers, professionals and experts to share information on the disabled's health.

초기사정을 위한 간호정보조사지의 임상내용 모델 개발

김영란,박현애,민열하,이명경,이영지 병원간호사회 2011 임상간호연구 Vol.17 No.1

Purpose: The purpose of this study is to develop a detailed clinical model for recording initial nursing assessment items, and to test the applicability of the model to facilitate semantic interoperability for sharing and exchanging nursing information. Methods: First, the researchers extracted items by analyzing initial nursing assessment records. Second, defining characteristics were identified by analyzing nursing records and reviewing the literature. Third, value sets for defining characteristics were identified and types and cardinalities of defining characteristics were defined based on the value sets. Finally, the detailed clinical model was tested through evaluation by experts and comparison with the initial nursing assessment in a clinical setting. Results: Sixty-one detailed clinical models were developed with 178 defining characteristics and value sets. The experts’ evaluation and comparison with the initial nursing assessment in a clinical setting showed that the detailed clinical model developed in this study was valid. Conclusion: Use of this detailed clinical model can ensure that the Electronic Health Record contains meaningful and valid information and supports semantic interoperability of nursing information. This use will promote quality in the nursing records and eventually quality of nursing care.