The Road to the Digital Nursing Future: Interoperability and Telematics Infrastructure are the Keys to a Continuity of Care in Nursing

The care sector is currently facing two major challenges: On the one hand, there is a lack of qualified personnel, and on the other hand, it must be ensured that the increasing number of elderly people can be cared for safely and efficiently. Digitization is indispensable if these two challenges are to be met. In this context, interoperability and the connection of care to the state telematics infrastructure in healthcare play an important key role.

As a result, the need for interoperable data exchange between systems in nursing is also increasing. This not only makes it easier for staff to work with existing devices and systems, but also promotes collaboration across departments and facilities. Networking the various nursing sectors creates a coherent Continuity of Care in Nursing, i.e. ensuring a consistently, high quality of care across sectors and facilities.

Figure 1: There is no such thing as care…

But especially when we talk about nursing, it is important to consider that nursing does not exist in reality. If we talk about professional care, for example, we have to consider three settings (clinical, outpatient and long-term care). These are not only regulated by partly different social codes, but have also developed their own documentation systems and qualities. In order for these care sectors to be able to exchange data and information with each other in a useful way, modern inland digitization with common interoperability standards in the facilities is necessary. And this does not just mean technical standards. Digital interoperability, i.e., the ability to work with other systems, has several levels that need to be taken into account.

First of all, there is syntactic interoperability. This must ensure that all exchanged information units are recognized correctly. This means that the systems must speak the same language, so to speak. And this is where the intersectoral dilemma begins. Because the systems often not only use different exchange standards, but often only self-developed (proprietary) interfaces are used. Without standards, it is very difficult to bring the systems together. The latest and most advanced data exchange standard for the healthcare sector is HL7-FHIR (pronounced “HL7- Feier”). This is now also preferred by politicians as a nationwide standard and is also a recognized, international exchange standard.

Semantic interoperability ensures that all systems understand the same thing about a piece of information. Nursing staff in particular love and maintain their abbreviations. And so it can quickly happen that one and the same abbreviation can already have different meanings on neighboring wards. If “UTI” is posterior wall infarction for internal medicine colleagues, it may be urinary tract infection for surgeons. This demonstrates the need to ensure semantics. Codes from terminologies or classifications can be used for this purpose. And this reveals a next problem in professional nursing in Germany. There is no binding reference classification in nursing. Each institution uses its preferred catalogs or classifications. Here, however, a national quasi-decision is on the horizon. In 2021, the German government licensed the SnoMed CT code system for Germany, setting a national standard with what is currently the world’s most comprehensive healthcare terminology. In addition, the order was also given to integrate the International Classification of Nursing Practice (ICNP) there. This means that a nationwide nursing classification will be available in SnoMed CT in the future. Thus, when data is exchanged via codes, it can be ensured that the nursing diagnosis in the clinic is also transferred to the software of the outpatient nursing service exactly as addressed. This shows that the professional nursing process, mapped in nursing classifications, also forms a technically connecting element of the nursing sectors. Each sector can continue to use its own sector-specific software, but must translate the content to the common classification code when exchanging data.

Structural interoperability is then a basic requirement for data exchange. This includes all data connections between devices and equipment. This begins with the cable connections and extends to the data protocols in the network. With the telematics infrastructure (TI), the legislator has created such a secure structure. You can think of this as a secure Internet for the healthcare sector, to which the healthcare facilities and thus also the various professional groups will be connected or are already connected. Patients, too, can use their electronic health cards to access functionalities of the healthcare network.

Gematik, founded in 2005 by the leading organizations in the German healthcare sector, is responsible for the introduction, operation and further development of the telematics infrastructure and its services. Many of the services have already been behind schedule for years. Nevertheless, some tools of the telematics infrastructure are already available today that may also be relevant for care.

Since the telematics infrastructure contains very sensitive user health data, access to this data highway is also highly regulated. If an insured person wants to use the functions, he or she needs the electronic health card (eGK) and a special access number (PIN). But healthcare facilities and their authorized employees also need special access authorizations, which healthcare professionals receive, for example, through the electronic health professional card (eHBA). In the future, this health professional card will be issued upon request by the electronic health professional register (eGBR) in Münster.

The heart of the TI is certainly the electronic patient record (ePA). Since 2021, everyone with statutory health insurance has a right to be provided with this by their health insurer. The ePA can be seen as a database in which the medical history, treatment data, medications, allergies and other health data of the insured can be stored uniformly across sectors and cases, nationwide. It thus also contains important information that is also relevant for nursing care. At present, however, very few insureds use this special app from their health insurer, which may have something to do with the still limited range of functions.

Another TI service is the electronic medication plan (eMP), which is the digital evolution of the national medication plan (BMP). This enables medication-relevant data to be exchanged via the TI and stored on the insured person’s electronic health card. This means that this relevant data can already be exchanged digitally between a clinic and a long-term care facility, for example, as part of the transfer process.

prescription and can be redeemed via app either on site or online. In the future, this will also significantly simplify the time-consuming medication process, for example in outpatient care. This means that a paper prescription no longer has to be collected from the doctor and then redeemed at the pharmacy, but can be conveniently done digitally.

In order to be able to exchange certain data in a structured manner in the telematics network, the sender and receiver must know these structures. To this end, the National Association of Statutory Health Insurance Physicians (KBV) was commissioned to develop so-called Medical Information Objects (MIO) for a wide range of topics (dental bonus booklet, maternity passport, vaccination card, etc.). The subsidiary MIO42, founded for this purpose, has already developed some of these MIOs. With the electronic nursing transition report, MIO42 also addresses nursing-related issues. The “nursing MIOs” are referred to as PIOs – nursing information objects. In the future, PIOs will enable nursing information systems across all sectors to exchange structured nursing data.

Since there is a particularly secure Internet for the healthcare sector with the telematics infrastructure, it is reasonable to assume that there is also a particularly secure e-mail service for the healthcare sector. This mail system is called “Communication in Medicine (KIM)” and allows, among other things, MIO and PIO to be exchanged across sectors.

But also such a modern communication option as a messenger, is to be mapped securely in the future in the telematics infrastructure. This service has been named TIM – Telematics Infrastructure Messenger.

There are a few more services, but the services listed are the most likely to be relevant to care. However, they merely represent a toolbox. What has been lacking, especially in nursing, is the mapping of these possibilities to practical, digital processes. For example, if you ask nursing professionals about the desired functions in the TI, you will find that the TI as such is often not known. However, if the digital possibilities are known, the solution of administrative tasks is very often desired. This is a very good reflection of nursing reality, in which administrative activities in particular account for a large proportion of the nursing workload. Often, no thought is given to relieving the burden on the nursing profession. Structured information on nursing-relevant risks, nursing diagnoses or nursing interventions from a transferring clinic are often not recognized as being as important as the possibility of no longer having to transport paper prescriptions from A to B. This is a good example of a situation in which the administrative workload is reduced. It is understandable that nursing professionals tend to think in terms of documents, functions and administrative tasks. Therefore, it is necessary to return to the level of nursing processes in a targeted manner. First the processes, then the technology!

A clever combination of TI services and PIOs at the process level could generate a high level of nursing-relevant relief here. I would like to illustrate this with an example. Modern nursing expert software, such as careIT Pro from NursIT Institute GmbH, supported by artificial intelligence, can significantly accelerate and simplify the nursing documentation process with decision support. At the end, the system generates a comprehensive electronic transfer sheet as PIO. In parallel, an electronic discharge letter and an electronic medication plan can be generated by the physician. This information can then be sent via TI and KIM to the follow-up facility and, for example, the primary care physician. The primary care physician, in turn, can now generate an electronic prescription and electronic prescriptions based on this information, which is then sent digitally via telematics infrastructure to the pharmacy or payer for approval. The pharmacy can now deliver the medication from the e-prescription to the patient, or the payer can send the approved prescription to the care provider. As you can see, this could significantly relieve the burden on nursing care. But the use of TI also opens up the possibility of completely new care delivery models. After all, telecare in particular requires a secure infrastructure and a connection to the patient or his or her relatives. This means that nursing staff can work over long distances,

• Advise, educate and instruct,

• carry out teleconsultations, e.g. in wound management,

• monitor nursing aspects,

• monitor technical assistance systems and

• exchange care data.

The increased use of digitization and the development of a secure infrastructure that enables the use of telematics solutions in healthcare require fundamental changes in nursing work. In this context, digitization in nursing can support the decision-making process and the streamlining of workflows, enable better access to information or promote the development of knowledge within nursing teams.

Nursing professionals must rise to the challenge of integrating new technologies into their daily work. However, they must also be supported in this with further training and education.

Nursing homes in particular will play a key role in the implementation of a Continuum of Care in Nursing, i.e., consistent nursing care for patients across sector boundaries. They house many people with multiple conditions who require support from healthcare professionals in a care setting. Telemedicine, telecare and telematics can help by enabling efficient processes that improve patient care while increasing the effectiveness and productivity of healthcare providers.

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