ROC van Twente: Nursing Education in Care and Technology

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1 ROC van Twente: Nursing Education in Care and Technology William TF Goossen a,c Anneke TM Goossen-Baremans b, Laura Hofte c, Bert de Krey c a Results 4 Care, Amersfoort, the Netherlands b Acquest Research, Development and Consulting, Koudekerk aan den Rijn, The Netherlands c ROC van Twente, Enschede Abstract The ROC van Twente offers nursing education at the diploma level (MBO), and is innovating the program to include a major minor structure for education about care and technology. In order to achieve this, a new position was created: the master docent care and technology. The task of the master docent includes development of education for nursing about technology, multidisciplinary cooperation, and service to health care institutions among others. The first development concerns a module about electronic patient records, standards, and semantic interoperability for continuity of care. The module is delivered to nursing students and to students from the information technology department, who work jointly in development teams. This paper describes the background, the development of the educational material and program, and the core content of the module. The core content are the care information models that link clinical materials with health care information standards. The program has started end November At the Medinfo 2007 conference the results of the course for the first group of about 40 students will be presented. Keywords: health informatics education, HL7, vocabulary, standards, continuity of care, electronic patient records Introduction National infrastructures for health care information exchange present a challenge to clinicians to adopt many standards. However, clinicians usually did not get education about standards, and even in this age, the curricula of schools of health professionals usually do not include such topics in the overcrowded programs, despite the growing need for it. Ageing populations and increasing numbers of people with chronic diseases change the focus of health care in such a way that the application of technology becomes essential. Example technologies applied include home care technology, video surveillance, smart homes, and information and communication technologies such as telehealth and electronic patient records (EPR). Increasingly, these technologies are integrated with each other, for instance based on internet standards. Thus, new kinds of healthcare emerge and for health care professionals there is an imperative to make sensible decisions about what technology to introduce in the care environment. The integration of technologies and the changes in health care delivery depend more and more on standardisation and quality assurance. This paper discusses how this approach to development of electronic messages and EPR is chosen as the topic for nursing education and for the education of application developers. A new educational program is introduced in this area, currently offered by the school of nursing and the school of technology of the ROC van Twente (Regional Educational Centre of Twente). Background In the Netherlands, the activities of the National ICT institute for Health Care ( [1] lead to the emergence of standards for electronic message exchange and development of electronic patient records [2]. The use of the EPR will be required by law in the near future. Thus there is a need for all health professions to learn using it, and to be able to support the development of EPR that address the clinician s needs. The Netherlands have based their information for health care strategy on the message paradigm, applying the international Health Level 7 version 3 (HL7 v3) standard for the safe exchange of patient information to authorized users via a national infrastructure. HL7 v3 has been used in about 20 projects now as a method to determine (clinical) user needs, modelling these needs, and implement clinical content in electronic messages. In addition, several vendors successfully base their electronic patient record systems on the HL7 v3 models. A key part of the developments include the HL7 v3 messages for continuity of care: this is the care provision domain [3]. This care provision message is meant for referral, acceptance, record exchange, discharge summaries and so on. It is a generic structure covering a standard way to identify sender and receiver, the patient, the purpose of the message and the expression of supporting clinical data. Clinical details are expressed in the care statements or clinical statements. The care statements themselves can vary significantly, but the way 1396

2 they are included in the message is consistent over different clinical domains. This has lead to the development of care information models [4, 5] that standardize clinical content in such a way it can be used and re-used in the HL7 v3 care provision messages [5]. The purpose of this approach is to realise semantic interoperability between health care information systems and technologies. Semantic interoperability is considered such that professionals receiving patient data electronically, clearly understand the meaning of the message and can adequately continue the required care. The school of nursing in Twente is timely with this approach due to the fact that the Twente region is a national pilot for the electronic patient record [7]. Health care providers in this region have requested more education in the area of care and technology, specifically about the use of information and communication technology. The program described below has been developed with input from representatives of the health care providers. The program is considered a try out for both education within the school of nursing, and for continuing education of the existing nursing workforce. These students from the school of nursing of ROC van Twente will eventually work as nurses, but with additional knowledge and experiences with the EPR. Design of the educational program The master docent care and technology The ROC van Twente is positioned in the east of the Netherlands. Twente is the front runner for the national implementation of the Nictiz spearhead projects: the medication record and the general practitioner to general practitioner record exchange. Therefore there is a perfect situational context for education. Students will be confronted with the developments in their practical / clinical traineeships. However, for a school of nursing it is difficult to gain immediate expertise to start participation. Therefore a new teacher role was established: the first master docent for diploma level education. The master docent has responsibilities to innovate the education, in this example about care and technology, to bring in knowledge and experience, in this example built up on many projects in health standards [7], to involve the teachers, in this example via a project team, and to deliver service to health care facilities in the Twente region. Service to health institutions is delivered for instance via participation in requirements gathering workshops and traineeships. To start the developments, a choice was made to keep it simple in the beginning, but at the same time take an example technology that is innovative and that relates to the national and regional developments of information and communication technology in health care. Thus, semantic interoperability was chosen as the leading principle to start the developments. Health care agencies in the region agree that they require nurses with skills and knowledge to participate in development of patient record systems and messages. The module care and technology The student groups participating in the minor care and technology include about 25 students from the school of nursing and about 15 students of the application developers program of the school of technology of the ROC van Twente. The teacher team is a multidisciplinary team of nurse educators and information technology educators. An overall goal for the module that started November 23 is that both student groups, each from their own perspective, understand the process of determination of information requirements, standardization and development and implementation of electronic patient record systems and electronic messages. The care information models are intended as a framework that bridges the often existing communication gap between system users and system developers. The minor program serves as a differentiation within the nursing and within the technical education. Therefore it is assumed that students do know the basics of nursing care and have experiences in traineeships before entering the minor program. For the technical students, an equivalent background in systems life cycle and methods applied is expected. Specific learning objectives / required competencies include: Multidisciplinary cooperation Communication and active participation Analysis of the need for care (nursing students) Analysis of information needs (application developers). Development of a care information model that includes purpose, description of variables, codes, HL7 v3 model, and technical data specification. Development of functional requirements for a electronic patient record system for continuity of care. In total, the program consists of 12 weeks of education. A total of 4 contact hours per week is presented in small working groups with a mix of nursing and technology students. In addition, the students need an average of 4 hours a week for reading and preparation of the teamwork. The program is presented in Table 1. The first five weeks are about the need for electronic patient records and messages, and the content of the messages. Then the application developers fall back on their normal program, and use time in between to work on the functional requirements and system design. In the meantime the nurse students have a clinical traineeship. For six of the nursing students, the 1397

3 traineeship involves participation in a nursing system development. In this particular setting, the ROC van Twente, a home care agency, and a vendor work together to create a new traineeship. After about 16 weeks, both the nursing students and the application developers come back to school and continue another 7 weeks of education on this module. These 7 weeks deal with the subjects presented in Table 1. They include continuity of care and requirements for electronic patient records and messages. Further, the development of a care information model is a core element. The students finish the program with a presentation of requirements, design and examples. Teaching materials include a module and reading materials, based on the work for the national information and communication infrastructure. Software: stroke care record system Another teaching tool is the electronic stroke care record system by Portavita [8]. Portavita is a vendor that agreed to have their software for stroke systems, still under development, made available for the students of ROC van Twente. This is a cost neutral arrangement, where both parties benefit: ROC van Twente gets access to a professional clinical information system for education, the vendor gets exposure and feedback on the system, and educational materials developed around the system become available for clients. Table 1: overview of the program for care and technology Getting acquainted with each other. Nurses: describe what nursing needs in the EPR. Technicians: support the nurses and apply methods for requirements gathering and functional design. Determine how to cooperate for 12 weeks. Week 2. Analyse information in care Nurses: explain which data are required in a stroke care record system. Technician: interview the nurses to get the requirements for a system. Week 3. Care information model 1 Study the care information model structure and start with making one example. Nurses the clinical and terminology part, technicians the model and technical specification. Week 4. Care information model 2 Develop a care information model, including clinical, terminology, HL7 v3 model and technical specifications. Traineeship intermezzo Nurse student ICT student Study the existing paper based methods for continuity of care during traineeship Develop a functional design for a nursing record system Week 5. Continuity of care for stroke Study needs for continuity of care and describe processes, professionals involved, roles, tasks and activities, information to be exchanged and apply UML modelling. Week 6. Continuity of care record Prepare a continuity of care record for stroke patients: contents, standards, sequence diagrams and functional design. Week 7. Review existing materials Select all relevant care information models from the repository Week 8. Classifications and codes Apply coding from standardised nursing and health vocabularies Week 9. Evaluate design against existing system Compare the functional design with existing system for stroke care Week 10. Functional Design Discuss the functional design Technology student presents to working group and makes final adjustments. Week 11. Preparation Prepare a presentation for the whole class and for teachers Criteria include: 1) Agenda and minutes, 2) Even distribution of the work in the small group, 3) The subject of the presentation has been negotiated with and approved by the teacher, 4) Apply presentation software, 5) Include the following: care information model, functional requirements, evaluation of group work, functional design Week 12. Final assignment Present as workgroup the results in public Evaluation Evaluate the course and work Care information models as core topic In order to have concrete materials available that are manageable for the students, the use of the care information models [5] is taken as the lead during the minor program. The care information models serve as a reusable building block within the framework of HL7 v3 Care Provision messages [2, 3, 5]. Care information models combine different standards materials and create valuable content for intelligent semantic interoperability [5]. They function as a communication bridge between clinicians and technicians and facilitate inputs into the technical development of electronic messages and EPR systems. The document structure for the care information models consists of meta-information, detailed description of the clinical instrument, and the reason for its application in practice [5]. It specifies clinical care using professional evidence, uses standardized terminology and coding, uses standard (HL7 v3) information models, and specify at the detailed level the technical requirements for the clinical content. Thus, the technical implementation according the HL7 v3 message and data specification are included via mapping tables, which are use- 1398

4 ful for EPR development as well. In most documents, one for every item of clinical activities, observation, or instruments, the current components include, in a recently revised format, the following components [5, 9]: 1. Version management and authorship 2. Explanatory introduction about the use of care information models 3. Aim of the instrument, index, scale, act, or observation 4. Scientific foundations / evidence base or other foundation such as guidelines 5. Description of variables / data items / values 6. Working instructions for practice 7. Interpretation guidelines for the results 8. Information on the topic relevant for care process 9. References / acknowledgements 10. An example of the instrument (when available) 11. HL7 v3 message model and description 12. Mapping table from domain to standardized terminology and to HL7 v3 domain message model 13. XML message example (extensible markup language) 14. Copyright issues, such as licensing of source materials, allowed use of care information models 15. Screen designs / screen shots for the instrument 16. Remarks, e.g. if a Dutch version is different from English version of an instrument 17. Contact information: how to contact the author(s) 18. Disclaimer A current overview of the 90 care information models, in the earlier less complete format, is available at the website: [4] Students work together in small groups to complete one (draft version) of a clinical relevant topic and specify it according to the above format for the care information model and complete the HL7 v3 specification. Exam The exam of the module consists of a presentation by the students of the design of a system for continuity of care, based on the professional and information standards. Nursing students must underpin their requirements from a patient care perspective. Application development students must substantiate their part with the analysis, modelling and design of a system (component) that meets nurses requirements. Future plans Currently the module is taught to the two student groups. However, once the module is delivered, more work for the master docent and the project group is waiting. The following new developments are on the agenda for 2007 and ROC van Twente wants to integrate the module to other health care providers educational programs. 2. The content and assignments will be put into an electronic learning environment, thus making it available to students wherever they are. 3. The minor program will be made available for continuing education for the health care agencies in the region Twente. 4. Other ROC s (diploma schools) have joined or will join and a wider spread of the materials and the education on these subjects is in preparation. Discussion and conclusion National and regional developments of information and communication technology in healthcare, such as electronic patient records and electronic messages, are emerging in order to deal with the changes in the health situation of the Dutch population. Due to results of standardisation efforts, useful materials become available for education. The ROC van Twente decided to develop a new role, the master docent care and technology to assist in establishing an innovative program for nursing students and technology students. The innovation includes several challenging areas. The first is a new kind of content: the sensible use of technology in the care environment. Secondly, the application of clinical, vocabulary, message and technical standards for exchange of information for continuity of care, based on a well established format of care information models. Thirdly, the use of electronic record software for stroke patients currently under development. Fourth includes the multidisciplinary student groups: nurses and technical developers, handling the same problem each from their own perspective. Fifth, a minor program within the existing education, indeed with a traineeship for currently few nurse students with a focus on system development. Finally, a project group from teachers, representatives of health agencies, and experts working together to achieve this. It is an exciting area of developments and we will be proud to present the results of the first course during the conference. Acknowledgments We want to thank the participation of all involved teachers and heads of departments of ROC van Twente, and the members of the project team from the health institutions in the Twente Region. Nelleke Plaisir of Acquest for her contributions to the module and reading materials. 1399

5 References [1] NICTIZ Nationaal ICT instituut in de Zorg. NICTIZ website. Available at Accessed November [2] Goossen WT, Jonker MJ, Heitmann KU, et al. Electronic Patient Records: Domain Message Information Model Perinatology. Int J Med Inf. 2003; 70 (2-3): [3] Health Level 7. Message standards. WWW documents. Accessed November [4] NICTIZ, Acquest and Portavita. Care Information Models. [Webdocuments, accessed November 2006]. [5] Goossen WTF. Intelligent semantic interoperability: integrating knowledge, terminology and information models to support stroke care. In: Park HA, Murray P, Delaney C (Eds). Consumer- Centered Computer-Supported Care for Healthy People. Proceedings of NI2006. Amsterdam etc. IOS Press, 2006: pp Studies in Health Technology and Informatics, volume 122. [6] Information Technology in de Zorg in Twente (2007). [Web documents accesed March 2007] [7] Goossen W. Representing clinical information in EHR and message standards: analyzing, modelling, implementing. HINZ Primary Care and Beyond: Building the e-bridge to Integrated Care. Eds: Christopher Peck & Jim Warren. Publisher: Health Informatics New Zealand (HINZ) & Health Informatics Society of Australia Ltd (HISA), [8] Portavita (2006). [Webdocuments. Accessed November 2006]. [9] Van der Kooij J, Goossen WTF, Goossen-Baremans ATM, Plaisier N. Evaluation of Documents that Integrate Knowledge, Terminology and Information Models. In: Park HA, Murray P, Delaney C, (Eds). Consumer- Centered Computer-Supported Care for Healthy People. Proceedings of NI2006. Amsterdam etc. IOS Press, 2006: Address for correspondence William Goossen, Results 4 Care, De Stinse VM Amersfoort, the Netherlands, williamtfgoossen@cs.com, results4care@cs.com 1400

SEARCHING SNOMED CT FOR CODING INFORMATION IN ELECTRONIC HEALTH RECORDS FOR STROKE PATIENTS. - Final report for NICTIZ and CAP-

SEARCHING SNOMED CT FOR CODING INFORMATION IN ELECTRONIC HEALTH RECORDS FOR STROKE PATIENTS - Final report for NICTIZ and CAP- Judith van der Kooij, Anneke T.M. Goossen-Baremans and William T.F. Goossen