modeling a terminology-based electronic nursing record system: an object-oriented approach

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odeling a terminology-based electronic nursing recordystem: An object-oriented approach

yeoun-Ae Parka, InSook Chob,∗, NamSoo Byeunc

College of Nursing, Seoul National University, Seoul, South KoreaDepartment of Nursing, College of Medicine, Inha University, 253 Younghyun-dong Nam-gu, Incheon 402-751, South KoreaEzCareTech, Seoul, South Korea

r t i c l e i n f o

rticle history:

eceived 27 July 2005

eceived in revised form

3 July 2006

ccepted 13 July 2006

eywords:

ystem modeling

lectronic nursing record

ursing terminology application

a b s t r a c t

Objective: The aim of this study was to present our perspectives on healthcare information

analysis at a conceptual level and the lessons learned from our experience with the devel-

opment of a terminology-based enterprise electronic nursing record system – which was

one of components in an EMR system at a tertiary teaching hospital in Korea – using an

object-oriented system analysis and design concept.

Methods: To ensure a systematic approach and effective collaboration, the department of

nursing constituted a system modeling team comprising a project manager, systems ana-

lysts, user representatives, an object-oriented methodology expert, and healthcare infor-

maticists (including the authors). A rational unified process (RUP) and the Unified Modeling

Language were used as a development process and for modeling notation, respectively.

Results: From the scenario and RUP approach, user requirements were formulated into use

case sets and the sequence of activities in the scenario was depicted in an activity diagram.

The structure of the system was presented in a class diagram.

Conclusion: This approach allowed us to identify clearly the structural and behavioral states

and important factors of a terminology-based ENR system (e.g., business concerns and sys-

tem design concerns) according to the viewpoints of both domain and technical experts.

zations have identified a need for standardized terminology

. Introduction

he nursing record is the formal documentation associatedith nursing care. In the past, the nursing record was merelydata repository that helped nurses to recall what they had

one, whereas currently the record represents a resource forhe reuse of primary information. To maximize the useful-ess of the nursing record, computer-based nursing recordsave been introduced as a part of the computer-based patient
ecord. The computer-based nursing record is more than aeries of documents in electronic form—it will be the corner-tone of a new way of managing nursing information. With an
∗ Corresponding author. Tel.: +82 32 860 8201; fax: +82 32 874 5880.E-mail addresses: [email protected] (H.-A. Park), [email protected]

386-5056/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights resoi:10.1016/j.ijmedinf.2006.07.005

© 2006 Elsevier Ireland Ltd. All rights reserved.

electronic nursing record, data collected at the point of carecan be used to assist nursing care at all levels of aggregation.As in an electronic patient record (EPR) system, the electronicnursing record has the ability to capture clinical informationand represent it using controlled terminology, which is widelyrecognized as a necessity [1].

Nursing terminology has seen much progress in recentdecades. Several national and international nursing organi-

c.kr (I. Cho), [email protected] (N. Byeun).

to facilitate the description, comparison, and communicationof nursing-care activities across settings, population groups,and countries [2]. The recent trend toward developing a more

erved.

mailto:[email protected]



dx.doi.org/10.1016/j.ijmedinf.2006.07.005

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rigorous foundation for nursing terminology brings with itseveral potential benefits, including greater expressivenessand more extensive reuse of data from heterogeneous sources[3–5].

However, the existence of appropriate terminology for cap-turing nursing information does not necessarily solve theproblem of how the information will be transformed fromconcepts in the nurses’ minds to codes in the computer’sdatabase. Users of existing nursing information systems typ-ically enter and retrieve structured data using so-called inter-face terminologies–terminologies that are optimized for end-user utilization, such as menu-driven data entry [6]. Theseterminologies generally take the form of enumerated clas-sifications, such as the North American Nursing DiagnosisAssociation Taxonomy I. But it is now recognized that thesetypes of terminologies may not be able to represent clinicalinformation in sufficient detail [5,7,8] nor provide sufficientcoverage [9]. The International Classification for Nursing Prac-tice (ICNP) developed by International Council of Nurses (ICN),which is a combinatorial terminology, represents one attemptto address some of the problems associated with these tradi-tional representations. However, the combinatorial nature ofthe ICNP makes it difficult to use directly, and this now appearsto represent a barrier to acceptance by nurse users [5].

This article describes how object-oriented analysis anddesign can be used in developing and implementing aterminology-based electronic nursing record system (ENRS).Here we describe how to design domain models and imple-
ment a model database that allows greater expressiveness andreuse of data. In addition, this study can be used to improvea multidisciplinary development team’s understanding of thefunctions and data processing procedures in the design and
Fig. 1 – Nursing information model for an el

i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 735–746

development stage, as well as of future maintenance proce-dures. We also describe the issues and lessons learned throughthis modeling process.

2. Background

2.1. The initiation of an ENRS design

In 2002, the Department of Nursing at the Seoul National Uni-versity Hospital, a tertiary teaching hospital with 1500 beds inKorea, initiated work on designing an ENRS that was plannedas part of the development of a paperless electronic medi-cal record (EMR) system for a new branch hospital with 900beds to be opened in May 2003. An ad hoc committee with sixnurse managers was formed to decide important issues suchas the controlled vocabulary, the nursing information model,and the user interface views. The committee recognized thatthe primary objective of an ENRS is to help nurses to manage apatient’s trajectory by tracing care activities and documentingall the events of the care processes.

The committee decided to use standard nursing terminol-ogy in order to support multipurpose applications of nursingdata such as quality improvement, decision support, and com-parison of nursing services. The ICNP beta version developedby the ICN was selected as the standard nursing terminologydue to its expressiveness and flexibility.

A nursing information model using a standard terminology
was designed and tested by the authors through the previ-ous study [10]. Fig. 1 shows the conceptual data flow betweenthe front-end and back-end of an ENRS. The upper part ofthe figure presents the content of nursing records expressed
ectronic nursing record system (ENRS).

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Table 1 – Nursing data views for an electronic nursing record system

Data view Information content Target nursing unit

Admission nursing assessment Demographics, admission information, history(health, illness, family, obstetric, menstruation,and immunization), physical assessment, andeducation

Inpatient units

Graphic record Vital signs, admission or post-operation day,bowel movements, diet, activity, and input andoutput

Inpatient units

Flow sheet Vital signs, admission or post-operation day,diet, position, input and output, medication,ventilator settings, signs and symptoms ofrespiration, gastrointestinal tract, wounds,consciousness, and skin integument, laboratory,and imaging tests

Intensive care units: MICU, NICU, SICU, and RICU

Nursing notes Nursing process Inpatient and outpatient unitsPreoperative check list Patient ID, nursing activities, and education Surgical, and obstetric and gynecologic unitsNursing discharge plan Discharge care plan, medication education, and

future appointmentsInpatient units

Operating room nursing record Operating room staff, procedures, operatingtime, anesthesia, materials used, and medication

Operating room

Nursing order check list Nursing orders Inpatient units

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MICU, NICU, SICU, and RICU stand for medical intensive care unit, nintensive care unit, respectively.

ccording to the nursing process. Core nursing data shoulde captured through the nursing process, which encompassesragmented types of nursing documentation in various struc-ured and unstructured forms. The lower part of the figureresents the components and roles of a terminology servernd a clinical data repository.

A terminology server manages three types of controlled ter-inology: clinical, administrative, and reference. In this study,

he ICNP beta version was used as the reference terminol-gy in the form of controlled nursing statements consistingf three data categories: nursing diagnosis, nursing activities,nd nursing outcomes. These statements were used by thend users to populate the clinical terminology during directata entry. These data categories are generated by terminol-gy managers through semantic combinations of the ICNPoncepts—these are referred to as precoordinated statements.he administrative terminology is a subset of the clinical ter-inology that is used for statistical classifications and data

omparisons across heterogeneous representations; exam-les are the NANDA Taxonomy, the Clinical Care Classification,nd the Nursing Interventions Classification. The adminis-rative terminology contains more abstractive and aggregatederms, and is used for analyzing and summarizing the clinicalata in the repository of an EMR system. However, it can alsoe used for clinical terms; the NANDA Taxonomy is an exam-le that can be used for the clinical terms in a list of nursingiagnosis in the nursing record.

Based on the above information model, 69 nursing formsrom 62 nursing units were analyzed to identify the type ofnformation being documented. The structured forms werenalyzed using a data matrix based on data items. We found
any similarities and a few difference between the forms.
or example, seven different types of forms were used toecord admission nursing assessments: basic demographicse.g., name, age, sex, ID number, and address), health history,

tal intensive care unit, surgical intensive care unit, and respiratory

family history, admission information, physical assessment,and admission education were recorded in all forms; whereasbirth history, immunization schedule, obstetric history, andpsychological history were only included in some of the forms.We derived an interface with eight data views encapsulatingthe existing 69 nursing forms by considering these similaritiesand differences (Table 1).

2.2. Object-oriented system design

In software development, there are several ways to develop amodel. The two most common approaches are from an algo-rithmic perspective and from an object-oriented perspective.The traditional view takes an algorithmic approach, in whichthe main building block is the procedure or function. Thisview leads the developer to focus on issues of control and thedecomposition of larger algorithms into smaller ones. How-ever, changes in requirements and system growth make it veryhard to maintain systems built with an algorithmic focus.

The contemporary view of software development takes anobject-oriented perspective. In this approach, the main build-ing block is the object or class. An object is generally drawnfrom the solution space, and a class is a description of a setof common objects. Every object is characterized by its iden-tity, state (i.e., there is normally some data associated with it),and behavior. This approach has become mainstream simplybecause it has proven effective in building systems in all sortsof problem domains and encompassing all degrees of size andcomplexity [11].

In traditional health information system design, clinicaldata and the rules for manipulating the data are built within
the applications. As the same set of data might need to beshared by clinicians with various professional orientations,different software modules of the system were created toaccess and manipulate the same data [12,13]. Often multi-

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ple copies of the same data are created for convenience, or asa result of undisciplined programming practices. When datais manipulated by different program modules operating withdifferent business process, inconsistencies in or corruption ofthe data are not uncommon. The level of program complexityand the extra efforts required to maintain data consistencyinevitably result in high costs [14].

The above factors mean that the data must be clearly sep-arated from the applications that manipulate them. This isachieved by allocating the data to a specific class of dataobjects that protects it, and the application of the data abstrac-tion (encapsulating and information hiding) principle. Thisapproach ensures the entrusted data as well as an object’sbehaviors are hidden from the users and other objects. Objectsuse messages (commands) to invoke methods (functions) toperform various operations that may produce a change in theobject’s state (attributes or data values). Only the methods ofan object have access to the members of its data set. Limitingthe access to and manipulation of data through the ‘autho-rized’ object and its methods ensures their accuracy and con-sistency. The properties of data abstraction, inheritance, andpolymorphism, and the ability of objects to effectively modelthe complexity of the real world make the object-orientedtechnique well suited to the design and development of com-plex applications [15]. These advantages of object-orientedtechnique prompted us to adopt this technique in the presentstudy.

3. Methods

3.1. The Unified Modeling Language and the rationalunified process

Visualizing, specifying, constructing, and documenting a soft-ware system requires the system to be viewed from severalperspectives. Different stakeholders – nurses, nurse man-agers, analysts, developers, system integrators, and projectmanagers – each bring different agendas to a project, and eachlooks at the ENRS in different ways at different times over thelife of the system.

To keep the analysis, design, implementation, and main-tenance of an ENRS manageable, the system as well as itsunderlying concepts has to be formalized and systematizedusing modeling techniques, in which basic components andconcepts can be defined for ease of use and to enable the for-mation of a comprehensive real-world system. For optimizedsolutions, the system should be viewed from enterprise, infor-mation, computational, engineering, and technology perspec-tives. The availability of such views facilitates the involvementof the different stakeholders and ensures the implementationof the needs of the users. This study defined such modelsand employed methodologies such as the Unified ModelingLanguage (UML) so as to appropriately specify the system com-ponents and their behavior.

The UML was selected in 1997 as a standard notation by
the Object Management Group out of the various method-ologies related to object-oriented technology [16–18]. Booch,Rumbaugh, and Jacobson initiated the UML, and proposed arational unified process (RUP) as a development process that
i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 735–746

could take full advantage of the UML. They suggested thatthe UML is not a standard for the development process, buta standard for the artifacts of development (semantic models,syntactic notation, and diagrams). The RUP captures the bestpractices in modern software development in a form that canbe adapted to a wide range of projects and organizations.

The above-mentioned features lead us to adopt the RUP asour project methodology. The RUP has four phases: inception,elaboration, construction, and transition. During elaboration,it is necessary to acquire a good grasp of the requirements andestablish an architectural baseline as a development standardfor the construction phase. During construction, the productis built up – often in several iterations – to the beta release.In the transition phase, the product is transited to the enduser and the project focus moves to end-user training, instal-lation, and support. The RUP is a model-driven approach, andseveral models are needed to fully describe the evolving sys-tem. The scope of this paper is limited to two iterations ofthe elaboration phase (Fig. 2). Therefore, we used use casemodels to identify what the system is supposed to do andthe system environment. We then identified the class dia-grams as a design model describing the realization of the usecases.

For the two models of use case and design, four artifactswere used: use case diagram, use case description, activitydiagram, and class diagram. For the effective application ofthe RUP and an accurate extraction of requirements, a mod-eling team was formed comprising a project manager, sys-tems analysts, user representatives, and nursing informati-cists. The project manager was responsible for identifying thedata flow and interface problems between the ENRS and otherrelevant systems. The system analysts and nursing informati-cists identified user requirements through regular meetingswith user representatives. User representatives consisted ofnine nurse managers from six major nursing units: inter-nal medicine, general surgery, intensive care unit, gynecol-ogy, pediatrics, and special surgery; they identified the userrequirements in consultation with the authors.

3.2. Modeling artifacts and specification

We selected a scenario approach to extract user requirements.We wrote a scenario designed to highlight the functional areaof focus (nursing note taking) within the specified operationalenvironment (nurse station) and time frame (recently). Afterobtaining approval for the scenario, we drafted a scenariostory based on an adaptation of one of the many such storiesavailable. We defined a scenario story as a probable sequenceof activities within our scenario. An excerpt of our scenariostory for the above scenario is provided below. Our scenariostory consisted of short structured sentences. The structure ofour paragraphs centered on the actions of a nurse over a shorttime period. The nurse’s actions within each paragraph werealways directed toward a single purpose. At the scenario storymatured, we drew a scenario activity diagram that depictedthe sequence of activities in the scenario story. Activities
that resulted in information exchange were identified anddrawn, and story actions were mixed with these informationexchanges as necessary to provide context. The principleobjective of the scenario activity diagram was to depict


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Fig. 2 – The rational unified pro

nstances of information exchange to aid in the identificationf potential use cases.

We formulated use cases using these scenarios, with these cases for a given scenario defined as a use case set.e recognized that use case sets for a given scenario var-

ed across operational environments and time. Operationalnvironments could include such entities as inpatient andmbulatory departments. A use case describing a nurse’s usef a computer could involve the use of a handheld computert the bedside of a patient. Use case sets for a given scenariolso change with time, such as an increasing trend towardoice data entry as the technology emerges. The use case seteported here corresponded to a tertiary teaching hospital dur-ng 2003.

After formulating use cases, we identified classes andheir relationships (which is one of the cornerstones of thebject-oriented approach). Here we report on the class dia-rams, which are divided into internal and external views.he external view contains external elements that correspond

o the people and things engaged in information exchangeutside the ENRS, whereas the internal view contains only ele-ents from the ENRS. An object-oriented methodology expert

eviewed modeling products and provided progressive feed-ack to the research team. This approach helped the team to

ook at the real world with object concepts and to describe theystem whilst following the RUP.

. Results

.1. Use case view

he use case view describes the behavior of the ENRS as seeny a nurse, a nurse manager, and a physician. The static

and the scope of this project.

aspects of this view were captured in a use case diagram(Fig. 3).

The use case diagram comprised eight use cases addressingrecord management and six use cases addressing nursing ter-minology management. The part devoted to the managementof nursing terminology was specialized to the ICNP Term Man-agement use case, Statement Management use case, and threeother use cases supporting functions of terminology manage-ment. Physician, Nurse, and Nursing Term Manager were iden-tified as the actors that use these use cases. The Physician isan actor who also represents other healthcare professionalsthat need to refer to nursing documents, such as nutrition-ists, pharmacists, radiation therapists, and staff of the insur-ance department. The Nurse (including the nurse manager)is an actor who participates in writing nursing documents,and supervises them for service quality assurance. The Nurs-ing Term Manager is an actor that takes charge of terminologymanagement, including the ICNP concepts and controlled pre-coordinated statements.

The dynamic aspects of use case view were captured in anactivity diagram (as shown in Fig. 4) that describes the flowbetween activities within the ENRS. The overall task flow ofthe ENRS was identified in the activity diagram. The NursingTerm Manager is in charge of creating, updating, and maintain-ing nursing terminology, and controlling the precoordinatedstatements that the nurse uses in the data input process. Theadministrative terms identified by the Nursing Term Managerare used in the analysis of nursing records for the variouspurposes of data aggregation. For example, the chief nursemanager of the internal medicine department may want to
retrieve the nursing diagnosis and the nursing activity listsidentified in patients admitted to the oncology nursing unitduring specified periods. He or she will use such informa-tion to understand trends in nursing problems or to distribute

740 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 735–746

Fig. 3 – Use case diagram of the ENRS.


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ursing resources during subsequent time periods. The ENRSetrieves the nursing problems and activities under the givenonditions, and returns the result in abstracted forms usingdministrative terms. It is a common task for managers tose these aggregating functions. The role of the Physician isimply retrieving and inquiring functions through the variousser interface displays.

Use case specifications were documented from scenariotories and identified use case properties. Use case spec-fications include the name, a brief description, the eventows, alternative flows, special requirements, and the pre-nd postconditions. Each flow of events was described inarrative form. Fig. 5 shows a part of specification for theursing Notes use case. In this specification, the event flowsomprise the normal data input, update, and delete sce-ario, while alternative flows contain exceptional scenar-

os including incomplete data input, data errors, and net-ork errors. The special requirements address items suchs authorizations and logging events of deletions and mod-fications to the statements in the database. Also con-traints such as those listed below (an example of a Nurs-ng Notes use case description) were identified as pre- andostconditions:

The authorization required to add, modify, or delete arecord.The system logs for tracing changes to a record.The requirement for a digital signature for legal reasons.

am of the ENRS.

4.2. Design view

The design view supports the functional requirements of thesystem, which are the services that the system should pro-vide to its end users. With the UML, the aspects of this viewwere captured in electronic nursing record class diagrams. Theuse cases of the ENRS can be divided functionally into twopackages, Nursing Records and Nursing Term Management, whereeach package includes a Nursing Records class diagram and aNursing Term Management class diagram.

Fig. 6 shows the class diagram for four types of nurs-ing data views: ‘admission nursing assessment’, ‘graphicrecord’, ‘nursing notes’, and ‘flow sheet’. This diagram consistsof seven entity classes, four boundary classes, four controlclasses, and their interrelationships. Eight entity classes thatare applicable to each nursing data view are also includedin this diagram. The classes used to store patient data wereomitted from Fig. 6 in order to decrease the complexity of thefigure. In this diagram, entity, boundary, and control classesare used for a database table schema, user interface, and dataprocessing, respectively. Each boundary class requests specificoperations related to control classes, and then each controlclass manipulates the data received from the related entityclasses.

The four use cases correspond to the classes of InitialAssessment, Vital sign Sheet, Nursing Notes, and ICU NursingRecord, respectively, in the class diagram. The Initial Assessmentclass is representative for the other three use cases of ‘preoper-


ursin
Fig. 5 – Partial example of a N
ative check list’, ‘nursing discharge plan’, and ‘operating roomnursing record’, because the classes for the three use casesare driven dynamically from the class of Nursing Record Itemsin the same way as for the Initial Assessment class. However,the classes for ‘graphic record’ and ‘flow sheet’ have fixed dataitems and are separated into the Nursing Record Item Selection,Vital sign Sheet, and ICU Nursing Record classes. The ‘nursingnotes’ case uses the Statement class directly. The class for a‘nursing order check list’ is not shown in this diagram becauseits data items come from the physician order contained in a
physician order entry system that is external to the ENRS.
In the notation of the UML, the rectangles of Fig. 6 provideinformation about each class. The top tier in each rectanglecontains the name of the class, and the middle tier contains

g Notes use case description.

the member items identified in the use cases. Member itemsare not synonymous with the data elements of a databaseschema–data elements are more detailed and discrete thanmember items in this project.

The class diagram of Fig. 7 consists of six entity classes,three boundary classes, four control classes, and their inter-relationships. The ICNP Terminology and Statement classes referto the ICNP beta version and controlled statements populatedfrom the ICNP, respectively. The ICNP Attributes class is intro-duced to increase the expression granularity of a controlled
statement, and is predefined as properties for each concept.For instance, the concept of ‘body temperature’ could havethe value of body temperature and the site of measuring as itsattributes. These attributes are used when a controlled state-


Fig. 6 – Class diagram of the Nursing Records package.

Fig. 7 – Class diagram of the Nursing Term Management package.


Table 2 – Example of recording a patient’s level of consciousness based on the design and implementation levels of themodel

Design level (entity class) Implementation level

Database table Tuples of field name and value

Nursing Record Item Nursing Record Item . . ., (Item ID, 1234), (Item, ‘consciousness’), . . ., (Statement ID, 5678), . . .

Statement Statement . . ., (Statement ID, 5678), (Statement Name, ‘observe consciousness’),(Statement Type, ‘activities’), . . .

ICNP Statement Map ICNP Statement Mapa (ICNP ID, 1111), (Statement ID, 5678), . . .

(ICNP ID, 2222), (Statement ID, 5678), . . .

ICNP Terminology ICNP Terminologya (ICNP ID, 1111), (English Name, ‘observing’), . . .

(ICNP ID, 2222), (English Name, ‘consciousness’), . . .

ICNP Attributes ICNP Attributesa (ICNP ID, 1111), (Attribute ID, E999), (‘Attribute Name, ‘’), . . .

(ICNP ID, 2222), (Attribute ID, 4444), (Attribute Name, ‘Level’),(Attribute Type, string), . . .

Admission Nursing Assessment Admission Nursing Assessment (Patient ID, 888888), . . . (Item ID, 1234), (Statement ID, 5678),(Attribute01, ‘alert’), (Attribute02, ‘’), (Attribute03, ‘’), . . .

f eac
a Indicates entries with two corresponding records. The field name o
ment precoordinated with the concept of ‘body temperature’is selected. The Statement Tree class is introduced to help nav-igate the statements in each nursing unit.

Given these two class diagrams, the database schemamight be designed in one of several different ways in theimplement phase. As an example, Table 2 indicates the infor-mation flow for a user wanting to enter the value of ‘level ofconsciousness’ of a patient at the view of ‘admission nursingassessment’.

5. Discussion and conclusions

The current widespread use of SNOMED® clinical terms inelectronic medical records marks a shift in emphasis awayfrom the notion of a mere ‘reference terminology’ towards aterminology system for direct use in clinical applications [19].The use of the ICNP marks the same type of shift in nurs-ing. However, there are concerns that the size and inherentcomplexity of this emerging combinatorial nursing terminol-ogy system make its direct application awkward. In orderto ameliorate this awkwardness, the combinatorial terminol-ogy has been mapped ‘behind the scenes’ [20,21]. However,it is not clear how the combinatorial terminology can beapplied to a real system in order to realize its benefits withusability.

To address this issue, we systematically approached theanalysis and design requirements of a terminology-basedENRS that was implemented in May 2003 at Bundang SeoulNational University Hospital, Korea. We reviewed previousstudies relevant to electronic nursing records in the con-text of an EMR. A few studies have considered the model-ing issues of a clinical information system [14], electronichealth records as an integrated platform [22], and the pro-
cess of undertaking activities in a hospital [23]. These stud-ies were concerned with the business processes and systemintegration at the national or enterprise level, whereas ourprimary concern was how to express the requirements con-
h unique ID is assigned randomly in this example.

sidering the characteristics of nursing records into the EMRcontext.

Nursing records traditionally contain documentation in anarrative form, which is easier to simply transfer to a com-puter screen in the form of free text. However, when usingfree text it is hard to apply standard terminology and obtaindata reusability. To overcome these problems, our analysis anddesign effort focused on structuring nursing content and theapplication of the ICNP as a nursing-specific terminology.

In this study, we considered a broad overview of the ICNP-based ENRS. Applying the dynamic data-view approach at thedesign level lead to the nursing documentation being encap-sulated as eight data views in which the ICNP was used todefine the clinical terminology. This resulted in all the patientnursing data being accessed systematically with the ICNP con-cepts.

Egyhazy et al. [24], Johnson [25], and Gu et al. [26] haveinvestigated the modeling methodology: Egyhazy et al. pro-posed a methodology for modeling computer-based patientrecords in a military health services system, and highlightedthe usefulness of an object-oriented analysis and design;Johnson modeled communication data using a conventionalapproach; and Gu et al. applied an object-oriented databaserepresentation to controlled medical terminology manage-ment. The latter two studies focused on data modeling ratherthan system behavior, which was designed separately withdata. In contrast, we attempted to obtain an understandingof both the static and dynamic aspects of the target system,by regarding them simultaneously at the modeling level. Theobject-oriented approach is now being widely used due to thecurrent trend of increasing complexity of hospital informationsystems associated with the increasing need for integratedhospital information systems, intelligent healthcare systemanalysis and decision support systems.

We initially intended to take advantage of being able todesign robust, reliable, reusable, and easily maintainableclinical systems using object-oriented techniques, but ourunfamiliarity with these techniques prompted us to begin by

a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 735–746 745

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Summary points

What was known on this topic before the study?

• It is necessary to use a standard terminology in theimplementation of an electronic nursing record sys-tem.

• The ICNP was developed by the ICN as a standard nurs-ing terminology to exchange nursing data and com-pare nursing services.

• Nursing data are traditionally recorded in both struc-tured and free-text formats, which make it difficult toimplement an ICNP-based ENRS.

What this study has added to our knowledge?

• We have demonstrated the usefulness of using a sys-tematic approach (use of OOAD, UML, and RUP) in theimplementation of an ENRS.

• We have described how we applied the ICNP to all nurs-ing documentation.

• We have described how to overcome the problems

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onsidering scenarios, for which we followed the formal RUPethodology with artifacts. This approach helped our team

o look at the real world with object concepts and to describehe system in a consistent manner. Also, this approachspecifically the use of use case descriptions) made it easier toommunicate with users who had little experience in the usef an ENRS. We showed and explained the simulations of the

nteractions described in the use case descriptions to the userso that they could understand how the system behaves andhat it looks like, which encouraged their active participation

nd feedback. The requirements extracted were transferredlearly to system designers and development personnel in ouream.

We encountered a few problems during the analysis andesign of the system. For example, there was considerableebate on whether free-text input should be permitted in theursing notes use case, which related to how strictly the use ofcontrolled vocabulary is enforced. Another issue was ambi-

uity in the information model adopted, which was relatedo the application of coded nursing data. It is expected thatursing data mapped with the ICNP concepts will be easilyetrievable for multiple purposes such as supporting clinicalecisions and comparing the effects of different nursing activ-

ties. However, whilst this type of application is a conceptualne with potential opportunities for informatics to contributeo the nursing domain, how to instigate this needs careful con-ideration. For other issues such as data access authorizationy different user groups (nurse students, managers, medicaltaff, pharmacy staff, nutritionists, and physical therapists),he user identification method, and co-sign between care team

embers were raised to be considered.The design process should consider that data objects can

ome from continuous monitoring equipment in intensiveare units, for example. Clinicians want to examine these datalong with other information in the ‘flow sheet’ data view,hich requires those data to be displayed into single screen

t time intervals defined by users. Medication data have alsosimilar design requirement. In the unit-dose system, someedication data come into an ENRS from a bar code system,hich required appropriate interfaces with the related sys-

ems.This study allowed us to clearly identify the structural and

ehavioral states of our terminology-based ENRS. In particular,he use of scenarios and use cases greatly helped in extract-ng user requirements, and in understanding the IT domainncluding the five artifacts. Additionally, this approach pro-ides a systematic method for the model to evolve continu-usly with consistent concepts, which is very important for aerminology-based system due to the continuing evolution ofursing terminology. In addition, the models can be reused in

urther system requirements such as developing an enterpriseata warehouse or integrating the ICNP with other healthcareerminologies such as SNOMED®.

cknowledgement

his study was supported by a grant of the Korea Health 21&D Project, Ministry of Health and Welfare, Republic of Korea

no. 02-PJ1-PG11-VN01-SV06-0010).

encountered in this field.

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