eCHIP Project
Cnnet Working Group 1 Draft Report
Information Standards and reference model for Community Nursing Information in the context of
the EPR/EHR/ICR
26 September 2003
WG1 Remit
The remit of WG1 was to develop information requirements for EPR for Community Nurses and underpin
these requirements with a structure and information standards that represent the nursing contribution to
clinical care along the patient pathway. This piece of work was designed to build on the results of the
consultation with NHSScotland Community Nurses, through the Community Nursing Network (CNNet),
published in the Interim Stage Report on the ‘Consultation on Information Requirements of Community
Nurses and Health Visitors for a Primary Care EPR’. This consultation tested the vision of the NHS
Scotland Strategy for Information and identified priorities for areas that EPRs would be expected to
deliver on for Community Nurses. It also put some flesh onto the levels of information required to support
clinical care planning and processes, to support clinical communication and to support secondary use of
information as a by-product.
Process
1. Community nursing care was represented in a concept map (Annexe 1). This was done with
reference to WG1 membership’s combined: expert experience in clinical practice and clinical service
development and management; knowledge of conceptual and theoretical models of nursing;
knowledge and experience of clinical informatics; and the literature.
2. The concepts and their relationships, known as propositions, were exploded into statements. In an
iterative process, the statements and concepts were refined until consensus was achieved.
3. These concepts were embedded into a reference model that represents areas of fundamental
functionality of EPRs required to support nursing care along the patient pathway (Annexe 2).
4. The concepts in the reference model were organised into a hierarchical structure that represent
functional and data relationships within an EPR architecture (Annexe 3).
5. The hierarchical structure was represented in a ‘record’ format, which is ‘familiar ground’ for grass
roots community nurses along with data items (Annexe 4).
6. The ‘summary level’ unit of information, Care Programme, which is a combination of a number of
concepts, places the nursing contribution to health improvement within the context of the ‘whole
system’ of health and care. WG1 identified 44 Care Programmes which have applicability across a
number of Community and primary care nursing practice areas (Appendix 5). This list is the baseline
of a ‘work in progress’ and is evolutionary in nature.
7. As a working example of how Care Programmes function as a summary level unit of information
WG1 focused on a clinical priority area which is of high relevance to community nursing practice,
quality and integrated care and communication across primary and secondary. This was CHD and
secondary prevention (Annexe 6). Terms and coding were cross-mapped to relevant existing terms
and codes available at national level e.g SCIMP codes, Diabetes Dataset, GMS Quality Indicator
code list. The datset within the Care Programme show preferred terms and codes. This example was
informed by taking data from systems where this Care Programme was in use.
8. The concept map was further refined after discussions with a linguist specialising in health
informatics.
Conclusions
9. Concept mapping is a useful tool for eliciting expert knowledge in a complex area such as community
nursing practice across many national clinical priority areas.
10. The template for Care Programme Information Standards demonstrates how clinical terms,
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
(referenced by clinical guidelines), data items, codes and electronic functionality can be drawn
together in a meaningful way to support the building of clinical information systems that are ‘fit for
purpose’ for community nurses. They can also supporting the clinical governance agenda by
providing by-product information for secondary use..
11. There is overlap with terms used with Care Programmes for Community Nursing and those of other
health care professions.
Recommendations
12. CNNet will act as a reference to ensure consistency of further development and will own the
datasets.
13. As a minimum Care Programme information should replace National Central Statistical returns for
Community Nursing ISD (S) 29/30.
14. As NHSScotland Boards and Trusts are at different levels of maturity with eHealth/IM&T
infrastructure support for EPRs/EHRs it would be up to them to implement Community Nursing
Information standards to the level of detail that fits with their eHealth/IM&T Strategy and Clinical
Record keeping standards.
Next Steps
15. Further validation of the Care Programme terms with community nurses and other healthcare
professionals is planned.
16. Cross-mapping work between Practice Team Information and CNNet dataset is planned.
17. Further work needs to be done on working up the content of the 44 Care Programmes to a stage
where the ISD Clinical Dataset Development Team can model them for use within National Datasets
and the NHSScotland Data Dictionary.
18. Work needs to be done on exploring resource use with Care Programmes.
19. Further work needs to be done on the use of Care Programme information to inform management,
planning and service development decisions.
20. An Impact Analysis of implementation of the Information standards at differing levels needs to be
undertaken with NHSScotland Boards and Trusts.
21. An ISD Impact Analysis of the change to National Statistical Central Returns needs to be
undertaken.
22. Use this work to inform specification requirements for electronic systems that community nurses
use/are expected to use.
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
ANNEXE 1
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
ANNEXE 2
Incoming
CARE
PROGRAMME
MANAGEMENT
referrals
lab results
ongoing coordination & collaboration
COMMUNICATIO
Outgoing N
referrals MANAGEMENT
ordering
continence supplies
equipment
ongoing coordination & collaboration
Discharge Summaries
Assessment
Health issue/problem/risk identification
Care planning
Care delivery
Evaluation
Outcomes
Patient
&
Nurse
BY-PRODUCT
INFORMATION
MANAGEMENT
Caseload profiling
Workload / workforce planning
Service planning development & delivery
Research,Education & development needs
Resource allocation
Policy development & planning
Final Draft
Figure 1: FRIDM: Functional Reference Information and Design Model (CNNetwork Working Group 1, 2003)
Chair: Veronica.Saunders@borders.scot.nhs.uk
Community Nursing Network: www.cnnet.org.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
ANNEXE 3
Referrals
Incoming
Lab results
Referrals
Continence Products
Communication Management
Ordering
Outgoing
Equipment
Lab tests
Ongoing care collaboration
Discharge summary
Evidence
Guidelines, standards,protocols
SSA (elderly)
Tools
Nursing (global)
Nursing (specific)
Assessment
Health problem/issue/risk
Reference Model
Assessment outcome
Care Programme Management
Socio-environmental factors
Medical Diagnosis
Aim
Care Planning
Goal
Evaluation
Care Delivery
Interventions
Caseload Profiling
Workload/workforce planning
By-product Information Management
Service Planning development and delivery
Research, Education and development
Resource allocation
Policy development and planning
Chair: Veronica.Saunders@borders.scot.nhs.uk
Community Nursing Network: www.cnnet.org.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
Measure
ANNEXE 4
FINAL DRAFT
Community Nursing electronic Record Information Requirements
25 September 2003
CORE INFORMATION
CHI/patient identifier
Surname
Forename
Date of Birth
Sex
Address
Postcode
Telephone
Ethnicity
GP Practice No
GP Practice Postcode
Allergies (optional if none)
Alerts (optional if none)
Current Medication
SUMMARY INFORMATION
Community Nurse Name & Details
Care Programme
Care Programme start and end dates
Care Programme end reason/outcome
BY PRODUCT MANAGEMENT INFORMATION
Community Nurse discipline
Care Programme
Care Programme start and end dates
Care Programme end reason/outcome
Ethnicity
NURSING INFORMATION (including *Nursing Classification and terminology)
*Health issue/problem/risk
*Intervention
Administrative information
Date and time of contact
Type and Mode of contact:- direct, indirect, telephone etc
Location
Medical diagnosis
(this concept may be expressed in Care Programme so doesn’t need duplicated)
Aim
( this concept may be expressed in Care Programme so doesn’t need duplicated)
Goal
(this concept may be expressed in Care Programme so doesn’t need duplicated)
Socio-environmental factors
(this concept may be expressed in Care Programme so doesn’t need duplicated)
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
ANNEXE 5
FINAL DRAFT
Care Programmes V1.4 and examples of their relevance to community nursing practice.
25 September 2003
Examples of possible Care Programme relevance to
practice – not complete or exhaustive
Care Programmes
DN
PN
HV
School
Nursing
Family
Health
Nurse
Assessment & identification of need and health promotion
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Enabling Carer Health and Wellbeing
Enabling Daily living skills with Arthritis
Enabling Daily living skills with COPD
Enabling Daily living skills with Motor-neurone Disease (Promoting
Independence)
Enabling Daily living skills with MS
Enabling Healthy Lifestyle with CHD
Enabling Healthy Lifestyle (and self care)with Diabetes
Enabling Mental Wellbeing
Enabling Patient understanding & decision making – Cancer
Enabling Positive Parenting
Enabling self care with Asthma
Enabling self care with Diabetes
Enabling Smoking cessation
Enabling Weight Control
Promoting Antenatal Health and Wellbeing
Promoting Child Health
Promoting Health with Pernicious Anaemia
Promoting Mens Health
Promoting Older Peoples Health and Safety
Promoting Postnatal Maternal Health and Wellbeing
Promoting Pressure ulcer Prevention
Promoting tissue viability after Leg Ulcer
Promoting tissue viability after Pressure sore
Chair: Veronica.Saunders@borders.scot.nhs.uk
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Community Nursing Network: www.cnnet.org.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
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Promoting Travel Health
Promoting Women’s Health
Promoting Young person’s Health
Rehabilitation of Daily Living skills after stroke
Restoring tissue viability (Promote Wound healing)- Leg Ulcer
Restoring tissue viability – surgical wound
Restoring tissue viability – traumatic wound
Restoring tissue viability (Promote wound healing) - Foot Ulcer
Restoring tissue viability -Pressure ulcer
Supporting Cancer chemotherapy
Supporting Child at Risk
Supporting Child protection
Supporting Continence – Bowel Dysfunction
Supporting Continence – Urinary Dysfunction
Supporting family functioning
Supporting Management of Diabetes
Supporting Older Person at Risk
Supporting Palliative Care (comfort) – Cancer
Supporting Palliative Care (comfort) – Renal disease
Supporting Palliative Care (comfort) – Respiratory Disease
Chair: Veronica.Saunders@borders.scot.nhs.uk
Community Nursing Network: www.cnnet.org.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
ANNEXE 6 WORKING EXAMPLE
FINAL DRAFT CARE PROGRAMME TEMPLATE – SCOTTISH COMMUNITY NURSING INFORMATION
STANDARDS
04/09/2003
CARE PROGRAMME: Enabling Healthy Lifestyle with Coronary Heart Disease
Owner: Community Nursing Network CNNnet
Service Use: District Nursing, Health Visiting, Practice Nursing
Clinical Guidelines Sources
Review Date: September 2004
SIGN 57, SIGN 41,
British Heart Foundation Heart Manual
Have a Heart Paisley CHD Integrated Care Pathway,
Definition:
The ‘Enabling Healthy Lifestyle with Coronary Heart Disease’ Care Programme describes the nursing contribution to meeting the needs of a patient
who has Coronary Heart Disease in order to reduce risk of disease progression and ill health through preventative, enabling and supportive measures.
To facilitate the use of Community Nursing Care Programme in electronic information systems data items have been defined and preferred codes
indicated where there is overlap with national datasets development, terminology and coding work. Examples of these are: the Scottish Diabetes Core
Dataset, SCIMP list, GMS contract codes.
Synonyms Register1:
CHD secondary prevention and chronic disease management
Renfrewshire and Inverclyde PCT
Cardiac Rehabilitation
Lothian PCT
1
Local arrangements within NHS Boards currently give rise to different Care Programme titles that reflect common core components and also allow for local flexibility
and ownership. Therefore a register of Care Programme titles that meet the standard criteria is maintained by CNnet
Dependency on Nursing Service Measures2
Further development work on Care Programmes to demonstrate resource intensity measures is recommended.
Local Variability and service priorities:
.Local service indicators around access, patient charter measures and waiting time standards will be additions to the core Care Programmes
Waiting time standard:
Waiting times can be measured from the date of receipt of a referral into the service to the date of the commencement
of the Care Programme
Duration of the Care
Programme
Duration of the Care Programme can be measured from the date of the commencement of the Care Programme to the
date of the closure of the Care Programme and discharge of the patient
2
Local practice development, staffing and skill mix issues impact on the ability to deliver Care Programmes Through previously completed nursing research, measures of nursing
resource utilisation can be developed on a Care Programme basis without the requirement to continuously collect additional data. This indicator would give greater accuracy in
comparative measurement to plan and develop services
NHSScotland Boards and Trusts will take decisions as to what level of information is required. If Care Management information is required the below dataset indicates the
preferred terms and codes that are in use. To prevent ‘reinventing the wheel’ any additional terms or changes should be discussed with CNNet who have access to National
Structures and mechanisms to support this work.
Clinical
function
Data item
Attributes/Parameter
HAHP
GMS
Contract
codes
GMS
Qaulity
Indicators
Assessment
Definition and comment
An assessment is
Medical Significant
factors
CHD
Myocardial Infarction
Angina
Ischaemic Heart Disease
CABG
Cardiac failure
hypertension
hyperlipidaemia
Renal disease
Peripheral vascular disease
Diabetes type 1
Diabetes type 2
TIA
CVA
Carotid Bruit
COPD
Asthma
Depression
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G3%
G30z
G33..
G3z..
792..
G58..
G20%
C324.
CHD1
CHD1
CHD1
CHD1
CHD1
BP1
Need clarification
G73z.
??C10E.
??C10F.
G65%
G61%
2472.
H3z..
H33%
Eu32z
DM1
No read codes yet for Type 1 and type 2
Stroke1
Stroke1
COPD1
Asthma1
A socio-environmental significant factor is
an area of concern to the nurse and patient
in the social and/or environmental domain
that impacts on the patient’s health status
Socio-environmental
Significant factors
Poor housing
Stressful lifestyle
Socially isolated
Lives alone
13E..
Read code requested
13HL.
ZV603
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
Mobility problems
Lack of family support
13CE.
ZV4F4
Smoking status is a measure of smoking
habit.
Smoking status
Thinking of stopping
Intend to stop
Been trying for >6months
Been trying for <6months
Do not need to
Never smoked
Ex-smoker
Smoker
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Blood pressure
measurement
BMI measurement
Underweight
Normal
Overweight
Obese
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Exercise level
Moderate Intensity Stage 1 < 6
months
Moderate Intensity Stage 1 > 6
months
Vigourous Intensity Stage 2
<6months
Vigourous Intensity Stage 2
<6months
Thinking about it
Does not want to do it
Does not need to do it
Intend to do it
Doing some but not enough
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137c.
Read code requested
Cannot code the time limits
137G.
137G.
Need clarification
1371.
137S.
137R.
246.. +
value
22K..
CHD3
CHD3
CHD3
CHD5 + CHD6
DM2
Measure of blood pressure expressed as a
value
Measure of body mass index – different
measurement tools are in use in clinical
practice
22K3.
22K1.
22K2.
22K5.
Measure of exercise levels of patient –
different measures are in use in clinical
practice
Accumulative 30mins daily on 5 days per
week
Accumulative 30mins daily on 5 days per
week
Continuous for 20-30 mins on 3 days per
week
Continuous for 20-30 mins on 3 days per
week
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Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
Care Delivery
Exercise limitations- orthopaedic
Exercise limitations- neurological
Exercise limitations- respiratory
HAD score
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Lifestyle assessment completed
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Read code
requested
Exercise assessment completed
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3213%
(this is an
ECG test)
Exercise assessment results sent to
exercise physiologist
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HAD scale completed
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Co-ordination of care
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388J.
Interventions
Referral to dietician
Referral to practice nurse
388J.
Sorry – this
cannot be
subdivided
in Read V2
– we could
request it if
necessary
8H76.
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8H71.
CHD2
Should this not be down below
An intervention is an action carried out by
a community nurse with, on or on behalf
of a patient to address a specific health
problem/issue/risk.
Types of nursing intervention are:
Health teaching guidance and counselling
Treatments and procedures
Case Management
Screening/surveillance
Completion of lifestyle assessment
according to local/national
guidelines/protocols
Completion of exercise assessment
according to local/national
guidelines/protocols
Clinical communication to other health
care professional according to local
protocols (eg ECCI)
Completion of Hospital Anxiety and
Depression scale according to
local/national guidelines/protocols
+Value
Clinical communication to other health
care professional according to local
protocols (verbal, written or ECCI)
Referral to Dietician according to local
protocols ( written or ECCI)
+date
Referral to Practice Nurse according to
local protocols ( written or ECCI)
Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk
+date
Dietary advice and guidance given
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8CA4.
Lifestyle change advice and guidance
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67H..
Smoking cessation advice and
guidance
Invited to smoking cessation clinic
Nicotine Replacement Therapy
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8CAL.
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8HTK.
8B2B.
Exercise advice and guidance given
Counselling and emotional support
Sexuality discussed
blood taken for lipids
Blood taken for cholesterol
Blood taken for triglycerides
Support to carer
Discharge summary sent to Practice
Nurse
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8CA5.
6714.
ZV6D1
41D0.
41D0.
41D0.
8O7..
Dietary advice and guidance given with
specific reference to Healthy
eating,Weight reduction,Lipid alteration
CHD4
NRT Prescribing according to local
guidelines and protocols
Can only code action not reason
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Community Nursing Network: www.cnnet.org.uk
Chair: Veronica.Saunders@borders.scot.nhs.uk
Deputy Chair: Alison.Forbes@tpct.scot.nhs.uk