Harmonizing and extending standards from a domain-specific and bottom-up approach: an example from development through use in clinical applications

OBJECTIVE Currently, the processes for harmonizing and extending standards by leveraging the knowledge within local documentation artifacts are not well described. We describe a collaborative project to develop common information models, terminology bindings, and term definitions based on nursing documentation systems, and carry the findings through to the adoption in standards development organizations (SDOs) and technical implementations in clinical applications. MATERIALS AND METHODS Nursing flowsheet documents from six large organizations were analyzed to generate a common information model and terminologies that fully expressed documentation across all systems, and were sufficient for evidence-based decision support, reporting, and analysis. RESULTS Significant gaps in existing standards were identified. The models and terminologies were submitted to and incorporated by SDOs, are published, implemented, and now serving as a foundation for an eMeasure. DISCUSSION There are few examples in the literature of success working through the standards development process from a bottom-up perspective. Subsequently, standards do not yet fully address the need for detailed clinical data that enables, for example, decision support as well as a range of reporting and analytic requirements. Recommendations from this project include transparent processes within SDOs, registries that make models and associated terminologies freely available, and coordinated governance processes. CONCLUSION We demonstrated the feasibility of using documentation artifacts in a bottom-up approach to develop common models and sets of terms that are complete from the perspective of clinical implementation. Importantly, we demonstrated a process by which a community of practice can contribute to closing gaps in existing standards using SDO processes.