Taxonomy Selection: Support Structure for the Transformation
of the Paper Based to Electronic Health Record
by Ann E. Dugas RN CNeph(C)
ABSTRACT
The Ottawa Hospital (TOH) is a1057 bed; tertiary care institution extended over three campuses and four satellites. For over a decade, the General campus of TOH has had online results reporting. The system has been available corporately since December 2001. The Institution needed to position itself to better amass, access and compare its clinical data. In 2004, TOH embarked on a project to transform its results reporting system into an electronic health record with the addition of computerized provider order entry and interdisciplinary clinical documentation.
While completing the analysis phase of the project, TOH embraced the Canadian Nurses Association mandate to select a classification system, which allows for collection coding and retrieval of data nationally.
Since classification systems have not been developed in line with electronic health records they vary in purpose, scope, structure and cost. Therefore it’s necessary to complete a detailed analysis to ensure the best selection for the patient care setting. The results of the evaluation process conducted by TOH will assist in building a data repository that is structured to support research well as clinical activity. The purpose of this paper is to share our selection and to provide a blue print of the selection process. The blue print includes a summary of literature review and the evaluation tools use to select the appropriate taxonomy.
ABOUT THE AUTHOR
Ann E. Dugas RN CNeph(C)
During a twenty year nursing career at the Ottawa hospital has worked as a Staff nurse, Researcher, Educator, Analyst and Manager. Led the implementation of Nephrology’s online documentation system in 1992. Followed by their evolution to a clinical documentation and order entry system in 1999. Participated in the original design and implementation for the corporate results reporting system in 1994. Currently is seconded to the Information Systems department as a Senior Business Analysts to participate in the transformation of the corporate results reporting system into an electronic health record via the implementation of clinical documentation and provider order entry.
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