abstract
As healthcare transitions to a value-based reimbursement model, electronic health records (EHR) and nursing documents in other health IT systems will increasingly be used to prove the contribution of nursing to this value. Nursing documents can also be used to measure the contribution of nurses to improving personal and population health outcomes, patient safety, surgical efficiency, and clinical effectiveness. Today, the contribution of nursing to personal and community health and nursing is difficult to measure and often invisible. This lack of visibility is partly due to the lack of unique identifiers for nurses. The nurse leader has determined that a unique nurse identifier is needed, otherwise the data cannot be aggregated and used to improve nursing practice. Nurses and their employers need a mechanism to track nursing licenses for job and location changes throughout the nurse’s career. Hospitals and health systems need to have the ability to uniquely identify nurses in EHR, enterprise resource planning (ERP) systems, and other health IT systems for recording, education, research, and training purposes. This article explains why a unique nurse identifier is necessary, and outlines the potential benefits and impact of adopting an identifier, as well as policy recommendations. Nursing knowledge: The Big Data Science Conference Health IT Strategy Working Group is collaborating with key stakeholders to implement the best solutions, such as using unique nurse identifiers to prove the value of nursing.

Introduction
As healthcare transitions to a value-based reimbursement model, electronic health records (EHR) and nursing documents in other health IT systems will increasingly be used to prove the contribution of nursing to this value. Nursing documents can also be used to measure the contribution of nurses to improving personal and population health outcomes, patient safety, surgical efficiency, and clinical effectiveness. Unfortunately, today, the contribution of nursing to personal and community health and care is difficult to measure, and often invisible. This lack of visibility is partly due to the lack of unique identifiers for nurses. The clinician who submitted the medical request can be identified through the National Medical Service Provider Identifier (NPI). Although it can be used, only a small percentage of the 4 million nurses are using this feature today.

Why is a unique nurse identifier required? Different identifiers can be used to track and classify nursing services for billing, staffing, and resource planning purposes. For decades, nurse leaders have recognized the need for unique nurse identifiers, otherwise data cannot be aggregated and used to improve nursing practice (Werley and Lang, 1988). Nursing Knowledge: The latest research from the Big Data Science Conference (2018) shows that more integrated documents in EHR, ERP and other medical IT systems are needed to enhance the unique nurse identification code for nurse care and outcomes. Nurses and their employers (physicians, hospitals, health systems) need a mechanism to track nursing licenses for job and location changes throughout the nurse’s career. Senior nurse practitioners also need identification for billing and coding. Hospitals and health systems need to have the ability to uniquely identify nurses in EHR, enterprise resource planning (ERP) systems, and other health IT systems for recording, education, research, and training purposes. This article explains why a unique nurse identifier is necessary, and outlines the potential benefits and impact of adopting an identifier, as well as policy recommendations.

background
In this dynamically changing healthcare environment, the goal of fully standardizing individual EHR data to be used as a basis for health information exchange has not yet been achieved. Although privacy and consent issues have been largely eased, concerns about the political, economic, and competitive risks of organizations within and across industries have been identified as major obstacles to unified data sharing and interoperability across populations (Mello , Adler-Milstein, Ding & Savage, 2018). If health information exchange is not implemented, there is no way to communicate with them in the process of sharing consistent information-not only about the person being treated, but also the health care professionals who provide the care-it is still not possible within and between organizations Quality measurement and care coordination. As the most trusted professional in the healthcare field, nurses can play a leading role by adopting a unique nurse identifier to help overcome known risks so that the nurse can use that identifier when recording the health and care of a specific individual.

As one of the basic professions of modern medical service, nursing and social contract, its responsibility is to evaluate the contribution of nursing practice to health promotion, injury and disease prevention, and pain relief. Nurses continually evaluate their clinical practice interventions to maintain and provide safe, high-quality personal health, care and results. Evidence supports the conclusion that nurses help prevent adverse events in medical and nursing care, but there is insufficient evidence to explain how nurses help prevent negative or positive results in patients (Englebright & Jackson, 2017). A unique nurse identifier may be one of the keys to understanding the impact of nursing practice; this identifier will enable nurse characteristics to be associated with customer characteristics in a larger set of health information data within or between organizations.

Nurse and midwife year
The World Health Organization declared this year as the Year of Nurses and Midwives. Our nursing informatics community and supporters will gather to celebrate today, this year and beyond the tireless efforts and inspiring work of nurses around the world.

Benefits of a unique nurse identification code
The widespread use of unique nurse identifiers will enable people to assess the impact of nursing practices, including the role of nurses in promoting safe and effective medical practices and enhancing enterprise resource planning. With unique nurse identifiers, scientific queries can be made, allowing researchers to measure and quantify care and its impact on health outcomes. With the help of unique identifiers, the assessment, intervention and outcome data mining for nurses can be used as a source and means to successfully study data points in the nursing literature of EHR and other health IT systems (Welton & Harper, 2016). It is also possible to check the correct use of nursing resources by using a unique nurse identifier to check the direct care time and the cost of each patient, as well as the relationship between the characteristics of the patient and the nurse and the cost of care (Nelson-Brantley, Jenkins & Chips, 2019) .

A value-based reimbursement model will require a basic understanding of the impact of nursing practices on patient outcomes in health promotion, disease prevention, and disease management. The lack of data related to the nursing process and patient outcomes hinders quality assessment and outcome research plans. The sub-optimal data collection method cannot provide reliable and effective basic nursing process and patient prognosis assessment, resulting in the lack of sufficient evidence in history to prove the contribution of nursing to patient care (Lang, 2008). Today, although we have developed measures to better capture the nursing process, the widespread use of unique nurse identifiers at the same time will make the collection of relevant and comprehensive data more feasible.

Internationally, the unique nurse identifier is actively viewed and adopted. The position paper entitled “Nursing Information and Knowledge Management” (Canadian Association of Nurses, 2006) calls for the establishment of a database that includes not only clinical data elements, but also data elements representing nursing practice and nurses. These Canadian nurses recommended the use of a unique registered nurse identifier as a key data element for health information interoperability and continue to advocate for its use today. In Switzerland, researchers from the Inselspital Nursing Research Department in Bern and the University of Basel use unique nurse identifiers to calculate detailed skill sets, including nurse education and roles (direct or indirect nursing, management, etc.) every 30 minutes. Increase in six nursing units (Simon, 2018). These data are used to calculate the nurse-to-patient ratio of each patient level in a sample of 240 patients. When aggregated to the shift level (1,100 shifts), they found an association between understaffing and increased adverse events (Gratwohl, Musy and Simon, 2018).

In the United States, although the advantages of using unique nurse identifiers have been recognized, they have not yet been realized. Werley and Lang (1988) suggested a minimum data set for nursing, including a unique nurse identifier. At present, there are two potential prospects for a unique nurse identification code in the country, and a dialogue between the main stakeholders has begun on its use in the health information system (Health Care Information and Management System Association (HIMSS), 2018 ). The two nurse identifiers are NPI and the National Board of Nursing National Committee ID (NCSBN ID). The use of unique digital identifiers for individual nurses in the EHR facilitates the aggregation, synthesis and release of data, research, and thus proves the value and contribution of nursing to improving health.

The Center for Medicare and Medicaid Services (CMS) requires medical staff to obtain NPI to obtain Medicaid or Medicare reimbursement as defined by CMS in the simplified HIPAA management: standard unique health identifier for health care providers; 2004 final rule (health And Ministry of Public Service-Office of the Secretary, 2004). Therefore, a unique digital identifier (such as NPI) is of primary interest to researchers. APRN that charges Medicare/Medicaid; recently there are registered nurses (RNs)/professional nursing organizations seeking to obtain Medicare and Medicaid professional nursing service reimbursements (for example, nursing coordination). The identifier can also help prove that each nursing team member is fully practicing quality care within the scope of their license and education; however, the use of NPI is restricted.

Both NPI and NCSBN ID are free and publicly available unique identifiers that can be used for all RNs. One of the strengths of NPI is that its database is cross-professional, and doctors and nurses are recognized as potential recipients of federal payments for services provided. No payment, no maintenance, such as annual updates (N

On the contrary, at the time of the NCLEX exam (National Board of the National Board of Nursing (NCSBN), 2018), an NCSBN ID will be automatically generated for each registered nurse and licensed actual/professional nurse. Each NCSBN ID is provided in the Nursys database. Nursys contains a set of systems and databases that contain nurse license and license discipline information, which is provided by the state nursing license issuing committees in the United States and its regions. Nursys regularly obtains nurses’ personal (name, address, etc.) and license information updates from participating state licensing boards. Nurses who were licensed prior to the implementation of NCLEX have been assigned IDs through a matching process with the state licensing board and added to the Nursys database, which also regularly updates their data.

The advantages of the Nursys system include the e-Notify® feature, which allows institutions to receive license status and can also track nurses electronically across multiple state licenses. In addition, the system also allows nurses to track their licenses by ID, and get the latest information about the status of the license, as well as notifications when the license is updated. All nursing licensing committees can use Nursys to edit information, including subject information and updated information. When a change occurs, both the organization and the individual RN can access the current state. Because Nursys grants public access, academics and quality experts also have the opportunity to determine the characteristics of the nurse population, such as medical surgery or intensive care nurses, and the relationship between these characteristics and patient prognosis. NCSBN maintains appropriate data security policies, procedures, and requirements, and performs assessments, audits, penetration testing, and vulnerability scanning to ensure data security.

Nursing Knowledge: Big Data Science Health IT Policy Working Group
By the University of Minnesota, School of Nursing (Delani, Prunelli, Alexander and Westera, 2016). As part of this action plan, the Big Data Science Health IT Policy Working Group was established to provide nurses with education, tools and resources, and to make them become knowledgeable advocates of health IT policy work important to nursing (nursing knowledge) : Proceedings of the 2015 Big Data Science Conference, 2015). The working group determined that a unique nurse’s identity certificate is needed to prove the value and contribution of nursing services to improving patient prognosis.

In view of the dual goals of health information exchange data standardization and better understanding and integration of nursing practice data, there is great hope for using unique nurse identifiers for all RNs (Institute of Medicine, 2011). The Health IT Policy Working Group supports the use of NPI for registered nurses who request reimbursement, but the challenges presented (including the need for each registered nurse to take action to apply for NPI) prohibit ease of use (Nursing Knowledge Big Data Science Conference, Health IT Policy Work Group, 2018). NCSBN ID provides ease of use and public availability of the current status of RN, resulting in a unique nurse identifier, which is meaningful for achieving twin goals. In view of these advantages, the Health IT Strategy Working Group advocates the use of NCSBN ID, a unique nurse identifier maintained and supported by NCSBN.

Policy recommendations and inspiration
The American Association of Nurses (ANA) released the question brief, “APRN with NPI: Distribution by Role and Country in 2010”, supporting NPI as the unique clinician identifier for Advanced Practicing Registered Nurses (APRN) (ANA, 2010). ANA advocates that all RNs have an NPI because this supports the policy priority that the scope of payment should be expanded to maintain consistency among all qualified medical professionals who provide high-value care coordination activities. As mentioned above, one of the obstacles for all RNs to obtain NPI is the manual intervention required for registration. However, CMS has confirmed the technical feasibility of the “bulk enumeration” process as defined in the final rule (“Medical Insurance and Medicaid Service Center”, 2004). Bulk enumeration will eliminate the need for those healthcare providers to apply for NPI individually.

The Office of the National Coordinator of National Health Information Technology (ONC) 2018 also defined NPI as a standard that meets the interoperability needs of representing healthcare providers. According to the Interoperability Standards Advisory (ISA), “In order to record care team members, it should be noted that the National Plan and Provider Enumeration System (NPPES) allows but does not require non-paying care team members to apply for NPI numbers to capture concepts

Taking into account the opinions of ANA and ONC, the “Nursing Knowledge: Big Data Science Health IT Strategy Working Group” recommends the following policy statement, advocating the use of unique nurse identifiers:

“The NCSBN ID should be used by key stakeholders as a nurse identifier to prove the value of nursing through research and enhance personal care and health outcomes through more comprehensive documentation in EHR, ERP and other health IT systems.” (Nursing Knowledge: Proceedings of Big Data Science Conference, 2018a pp.11).

The policy statement advocates that the National Nursing and Medical Associations, associations, organizations, and government agencies need to promote the use of NCSBN ID to reveal the impact landscape of nurses’ evidence-based practice in the current value-based nursing model through scientific inquiry. By extracting nursing-specific data, such as data from integrated documents and nursing administrative records in EHR, ERP, and health IT supplier information systems, a unique nurse identification vision and mission can be realized.

Advocacy work
The development of unique nurse identifier policy recommendations relies on the recognition and understanding of many participants who are committed to using the interoperability standards of comprehensive nursing document data to influence value-based care, research, delivery of quality care and health outcomes . To this end, the “Nursing Knowledge: Big Data Science Health IT Policy Working Group” will regularly evaluate the unique nurse identifier position statement, and distribute educational tools and resources related to health IT policies to key decision-making groups based on the ID strategy and purpose.

To date, achievements in influencing the health information technology policy ecosystem to further use the national nurse identification code include the development of position statements and the use of major advocacy/leadership opportunities related to nursing. Through cooperation with like-minded groups, including AMIA, ANA, Nursing Informatics Alliance, American Academy of Nursing, HIMSS, NCSBN, and ONC (Nursing Knowledge: Big Data Science Conference Proceedings, 2018b), policy work has been promoted.

Through outreach, education and promotion strategies, the unique nurse logo advocates continuous development. Active cooperation with ANA, NCSBN, medical institutions and medical IT providers will continue to be the focus of the development of unique nurse identification codes. By using the implementation of NCSBN ID as a potential way to evaluate the future adoption of NPI as the sole nurse status, collaboration with ANA will continue. The partnership with NCSBN, which maintains the NCSBN ID in the Nursys database, consolidated the policy statement and enhanced collaboration (HIMSS, 2018). The Health Information Technology Policy Working Group will also explore funding opportunities to support proof-of-concept trials and analyses to determine the technical feasibility of using unique nurse identification; proof-of-concept trials and analyses will include at least one healthcare organization working with an EHR provider ( Nursing Knowledge: Proceedings of Big Data Science Conference, 2018c).

in conclusion
A unified voice is essential for advocacy work related to the adoption of unique nurse logos in EHR, ERP systems and other health IT systems for the purpose of documenting, education, research and training in the United States, similar to what is currently happening globally Promotional practices. This identifier can then be used to measure the impact of care on individual and population outcomes, patient safety, operational efficiency, resource allocation, and clinical effectiveness. Nursing knowledge: The Big Data Science Conference Health IT Policy Working Group will continue to work with ANA, NCSBN and other interested stakeholders to achieve the best solutions, such as using unique nurse identifiers to prove the value of nursing.

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