¹Medizinische Universität Lausitz - Carl Thiem, Cottbus, Germany

Text

Introduction: High-quality healthcare requires the systematic use of not only medical but also nursing and therapeutic data. While interoperable routine data structures have been established in medicine – e.g., through the Medical Informatics Initiative (MII) – comparable standards in nursing and therapy are still lacking.

This project aims to develop and implement an integrated concept for standardizing nursing and therapeutic routine data and their key indicators within the model region of Lusatia. The approach is intended to be scaled nationally to ensure international compatibility in nursing and to set new standards in therapeutic care and research.

The data will be integrated into the existing Data Integration Center established under the MII, enabling standardized, privacy-compliant processing and access for research at regional, national, and international levels.

Standardized data collection in nursing and therapy is also expected to consolidate resources and improve care quality.

State of the art: In 2023, the INTEROP Council published a position paper outlining a patient journey and recommending a nursing core dataset, highlighting the need for standardized, evidence-based data and interprofessional interoperability [1].

International comparisons of Nursing Minimum Data Sets (NMDS) show structural differences. Elements like diagnoses, interventions, and outcomes vary, and nursing intensity is often underrepresented [2].

Attempts to adapt the Belgian B-NMDS II to German hospitals failed despite structured efforts [3].

In the therapeutic field, no nationally standardized core datasets exist. Current approaches – e.g., for LVAD therapy [4] or rehabilitation [5] – remain isolated and not widely adopted.

Concept: The project aims to develop a scientifically grounded, cross-sectoral dataset for nursing and therapy.

Development includes a structured literature review, analysis of best practices, documentation review, and a participatory process with experts from nursing, therapy, and data science.

An interoperable, scalable structure will be implemented in a model region, with long-term plans for national and international transfer.

Suitable nursing classification systems (e.g., NANDA, NIC, NOC) will be evaluated for their ability to represent the dataset meaningfully.

Interoperable use cases will be defined for specific nursing subdomains to expand the core dataset and enable context-specific data collection.

A parallel approach is planned for therapy. As comprehensive documentation and classification systems do not exist across all therapy domains, a core dataset and corresponding documentation structure will be newly conceptualized.

Implementation: Documentation using nursing classifications (diagnoses, interventions, outcomes) will first be introduced at the Medical University Lausitz – Carl Thiem and then piloted in the model region.

A similar process is planned for therapy, in close coordination with experts from both fields.

Lessons learned: Although various nursing classification systems exist, their use remains inconsistent. The project’s structured assessment will identify systems suitable for integration based on expert consensus.

In therapy, existing models are context-specific and not broadly transferable, highlighting the need for a new, practice-oriented approach.

Standardization in nursing and therapy involves technical, semantic, and structural challenges. The modular and participatory project design is well-suited to address these and establish research-relevant data structures.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.

References

[1] Interop Council. Positionspapier Arbeitskreise „Pflege Journey“. Berlin: gematik GmbH; 2023 [cited 2025 Mar 18].
[2] Eberl I, Bartholomeyczik S. Die Übertragung des Belgischen Nursing Minimum Data Set II (B-NMDS II) auf bundesdeutsche Krankenhäuser. Ergebnisse der ersten Untersuchungsphase zum Übersetzungs- und Adaptionsprozess des Instruments. Pflege. 2010 Oct; 23(5):309-319.
[3] Ranegger R, Eberl I. Nursing Minimum Data Sets aus der elektronischen Patientendokumentation. In: Swoboda W, Seifert N, editors. Digitale Innovationen in der Pflege. Berlin, Heidelberg: Springer; 2024. p. 121–152. DOI: 10.1007/978-3-662-67914-2_5
[4] Puñal-Riobóo J, Faraldo Vallés M, Nogueira Uzal N, Patrick H, Varela-Lema L. A minimum dataset for destination therapy with left ventricular assist device: the evidence that matters to decision makers. International Journal of Technology Assessment in Health Care. 2025;41(1):e8.
[5] Young AM, Chung H, Chaplain A, Lowe JR, STARS Rehabilitation Dataset Development Group, Wallace SJ. Development of a minimum dataset for subacute rehabilitation: a three-round e-Delphi consensus study. BMJ Open. 2022 Mar;12(3):e058725.