Integration of Nursing Informatics, Integration of Nursing Informatics, Nursing Classification Systems, and Nursing Classification Systems, and

Nursing PracticeNursing Practice(Nur 603)(Nur 603)

Presenter:

Russell McGuire, MSN, RN

Director of Clinical Services, DHS

Appalachian Regional Healthcare, Inc.

Appalachian Regional Appalachian Regional HealthcareHealthcare

History Formed out of old UMWA hospital system Home health services 1968 Current organization

8 hospitals 16 primary care clinics and centers 8 home health agencies and branches Long-term care DME

ARH System Center – Home ARH System Center – Home ServicesServices

32,000 visits in 1969 Over 450,000 for FY 97-98 Services provided in 2 state region

Eastern Kentucky Southern west Virginia

Nursing InformaticsNursing Informatics

Nursing Informatics - DefinitionNursing Informatics - Definition

“The use of technology and/or a computer system to collect, store, process, display, retrieve, and communicate timely data and information in and across health care facilities that: Administer nursing services and resources; Manage the delivery of patient and nursing care; Link research resources and findings to nursing

practice; Apply educational resources to nursing education”

(Saba, 1996).

Nursing Informatics - FocusNursing Informatics - Focus

Nursing informatics focuses on the use of “nursing information system” (NIS) to administer nursing resources: To assist in effective information management; Monitor the quality, effectiveness, and

outcomes associated with the provision of care; Protect the confidentiality and privacy of

patient data.

Conceptual FrameworkConceptual Framework

Data Information Knowledge

Nursing Process

Information and Communication Technology

Atomic level Synthesis

(raw facts) (interpreted facts) (synthesized information)

Nursing Classification SystemsNursing Classification Systems

Reasons for Classification System Reasons for Classification System DevelopmentDevelopment

To standardize nomenclature To expand nursing knowledge To develop information systems To teach decision making To determine nursing costs To allocate nursing resources To communicate nursing to non-nurses To link nursing knowledge

Source: McCloskey, J. & Bulechek, G. (1996) Nursing intervention classification.Mosby Publishers)

Relevant BackgroundRelevant Background Basic concepts for information systems:

Nursing data: refers to unstructured raw facts; Are discrete entities; Lack interpretation. Forms the basis for a nursing information system.

Nursing information: data that has been given form and has been interpreted.

Nursing knowledge: synthesized information derived from the analysis of data that has been processed.

Relevant BackgroundRelevant Background

Nursing Data Standards needed for the management, documentation

and communication of nursing diagnosis, interventions, and outcomes (patient and nursing sensitive).

researched and supported by the ANA Council on Computer Applications in Nursing and the NLN’s Council for Nursing Informatics.

HistoryHistory

1970: ANA recommends that “nursing process” be used as the standard for documenting nursing practice.

1970s: Nursing Diagnoses researched and approved by the North American Nursing Diagnosis Association (NANDA).

1980: ANA’s Social Policy Statement - “Nursing is the diagnosis and treatment of human responses to actual or potential health problems”.

HistoryHistory

1985: Nursing Minimum Data Set (NMDS) researched/developed by Werley and Lang.

1986: ANA approves polices to develop a classification system designed for all nursing practice settings.

1988: ANAs Broad of Directors accept the NANDA Taxonomy I Revised.

HistoryHistory 1988: ANA endorses the Conference on Research

Priorities in Nursing Science. Identified two needs: “the need for standardized data sets which document

nursing care process across settings and a taxonomy to classify nursing phenomena and allow the common use of terms”.

1990: ANA House of Delegates recognizes the Nursing Minimum Data Set (NMDS). describes the nursing care of patients and their caregivers in a

variety of settings. provides comparability across clinical settings. demonstrates trends in nursing care. provides data for policy research and policy decisions.

HistoryHistory 1991: ANA Congress of Nursing Practice mandated

the formation of the Steering Committee on Databases to Support Clinical Nursing Practice. Purposes:

propose policy and program initiatives regarding nursing classification systems.

build a national database for clinical nursing practice. coordinate public and private development of

databases.

HistoryHistory 1992: ANA Database Steering Committee formally

recognizes four nursing vocabularies: NANDA - North American Nursing Diagnoses Association. The Omaha System - Omaha VNA (Martin & Scheet) Home Health Care Classification System - Georgetown

University (Saba). Nursing Intervention Classification - University of Iowa

(McCloskey & Bulechek)

1993: Development of the International Classification of Nursing Practice.

Rationale: Rationale: ““Next Generation Nursing Next Generation Nursing Information Systems: Essential Characteristics for Information Systems: Essential Characteristics for Professional PracticeProfessional Practice””

Nursing information systems exists within the context of the total continuum of the “integrated patient record system”.

Health care is and will continue to be an information-intensive endeavor.

Information is a critical resource in the health care delivery environment.

Nursing Practice is essentially an information-processing activity.

RationaleRationale Nursing information is essential to the

accuracy of integrated systems (both health care delivery and information systems).

Patient-specific data are the focal point of a totally integrated patient-record system.

Atomic-level data, captured within a Nursing Information System will be used for many purposes.

Users Data/Information Scope

Administrators, Costs of care by category of patient. Agency-wideResearchers, Accreditors Number of patients admitted with specific diagnosis. DataQuality managers Volume of tests, procedures, interventions, outcomes.

World health officials General health status and WorldwidePolicy makers, Researchers health-related needs DataLawmakers of individual nations.

Analysts, researchers, Comparisons of treatments, outcomes, Community/Quality management, and costs by locality and by agency. Region-widePublic health officials Incidence and prevalence of diagnosis by region. Data

Policy makers Trends in incidence, prevalence, Nationwide Lawmakers, researchers outcomes, and costs by region, by DataInsures diagnosis, by type of agency.

ABSTRACTED, SUMMARIZED, AGGREGATED

ABSTRACTED, SUMMARIZED, AGGREGATED

ABSTRACTED, SUMMARIZED, AGGREGATED

ABSTRACTED, SUMMARIZED, AGGREGATEDCaregivers Atomic level patient-specific data: e.g..assessments, Individual Agency departments, diagnoses, interventions, diagnostic test results, procedures, Patient Quality managers, Insurers treatments, hours of care, outcomes. Data

RationaleRationale Data and data elements required for nursing

information systems are evolving. To ensure high-quality practice, nurses need

access to sources of data that are ”beyond institutional, patient-specific data”.

“There will always be a need for human interpretation of computer-processed data”.

Where is all this Leading?Where is all this Leading?Unified Medical Language SystemUnified Medical Language System

1986: National Library of Medicine initiates the Unified Medical Language System (UMLS).

Goal: to develop a computer-based information resources for health professionals. designed to link information resources

scientific literature computer-based patient records factual databases expert systems other health related databases

Where Is All This Leading?Where Is All This Leading?Unified Medical Language SystemUnified Medical Language System

Three resources related to the UMLS: Metathesaurus - set of terms and concepts

associated with several biomedical vocabularies.

Semantic network - links the Metathesaurus vocabularies together using semantic concepts.

Information sources map - a description of available databases.

Where Is All This Leading?Where Is All This Leading?Unified Medical Language SystemUnified Medical Language System

Using the same concept, the NLM is linking the recognized nursing vocabularies (primarily for this discussion NANDA, NIC, and NOC).

This process of recognition and inclusion of nursing vocabularies, taxonomies, and classification schemes into the NLMs Metathesaurus can been demonstrated in the development of the unified nursing language system.

Where Is All This Leading?Where Is All This Leading?Unified Nursing Language SystemUnified Nursing Language System

ANA database steering committee developing a common nursing language known as the unified nursing language system (UNLS).

Criteria for inclusion in the UNLS: Clinically useful for making diagnosis, intervention, and

outcome decisions. Terms unambiguous, clearly and accurately defined. Tested for validated clinical use and reliability of

vocabulary terms. Accompanied by evidence of a process for periodic review

and appropriate methodology for research and testing.

Where Is All This Leading?Where Is All This Leading?Unified Nursing Language SystemUnified Nursing Language System

To date the ANA database steering committee has recommended the four “recognized” nursing classification schemes for inclusion in the UNLS.

The UNLS will: Allow for integration of patient data, scientific data, and

bibliographic data. Bring information to the bedside to improve clinical

decision making. Identify linkages and associations across vocabularies

and taxonomies. Linking clinical data, cost data, educational case data.

NANDA,

NIC,

NOC,Impaired ?

Are you ……

Integration Into Nursing PracticeIntegration Into Nursing Practice

ARH Experience With Nursing ARH Experience With Nursing Classification SystemsClassification Systems

Information systems development. Need for standards-based, evidenced based

practice guidelines. Need for standardized language across the

continuum. Across nursing practice settings. Integrated from a trans-disciplinary, integrated

healthcare delivery perspective.

ARH Experience With Nursing ARH Experience With Nursing Classification SystemsClassification Systems

ARH reviewed the current literature related to nursing classification systems.

Review initiated in the information systems department.

Input from nursing executive staff (acute care / home health).

ARH Experience With Nursing ARH Experience With Nursing Classification SystemsClassification Systems

Nursing classifications reviewed. NANDA (north American nursing diagnosis

association). NIC (nursing intervention classification). NOC (nursing outcomes classification). Omaha - home health nursing practice. HHCC - home health nursing practice.

Features, advantages, disadvantages for use in ARH determined.

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: NANDAClassification Systems: NANDA

NANDA - north American nursing diagnosis taxonomy I revised.

Features. Research based development. 133 nursing diagnoses applicable to different

practice settings. Continued research and expansion. Based upon the nine human response patterns,

forming the abstract conceptual level.

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: NANDAClassification Systems: NANDA

Advantages. Comprehensive listing of nursing diagnoses. National and international recognition.

Disadvantages. Does not address specific interventions or

outcomes.

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: NICClassification Systems: NIC

NIC - nursing intervention project (Iowa project.

Features. 433 documented, researched nursing

interventions.

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: NICClassification Systems: NIC

Advantages. Most comprehensive listing of researched

nursing interventions. Documented linkages to AHCPR guidelines,

nursing diagnoses. Continued research efforts to establish linkages

to patient outcomes. Disadvantages.

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: OmahaClassification Systems: Omaha

Developed by the VNA of Omaha Three classification schemes:

Problem classification (40 client problems) Intervention classification (62 interventions)

Health teaching, guidance, and counseling Treatments and procedures Case management Surveillance

Problem rating scale

ARH Experience With Nursing ARH Experience With Nursing Classification Systems: HHCCClassification Systems: HHCC

Developed by dr. Virginia Saba (Georgetown university).

Consists of : Nursing diagnosis - 145. Nursing intervention - 160. Home care component - represents clusters of

functional, behavioral, physiological, and psychological health care patterns.

Numerically coded for information system use.

Extended Health Enterprise ModelExtended Health Enterprise Model

PopulationPopulationPopulationPopulation InsurersInsurersInsurersInsurers

EmployersEmployersEmployersEmployers

RegulatoryRegulatoryAgenciesAgencies

RegulatoryRegulatoryAgenciesAgencies

NetworkNetworkNetworkNetwork

ManagedManagedCareCare

InpatientOutpatientEmergencyTesting

InpatientOutpatientEmergencyTesting

SNFNursing Home

SNFNursing Home

NursingIV PharmacyHMEAncillary ServicesHospice

NursingIV PharmacyHMEAncillary ServicesHospice

PhysiciansDentalGroup Practice

PhysiciansDentalGroup Practice

Urgent CareSurgicenterDiagnostic Centers

Urgent CareSurgicenterDiagnostic Centers

Mental HealthSubstance AbuseMental HealthSubstance Abuse

AffiliatedAffiliatedServicesServices

AffiliatedAffiliatedServicesServices

AcuteAcuteCareCare

AcuteAcuteCareCare

Long TermLong TermCareCare

Long TermLong TermCareCare

HomeHomeHealthHealthHomeHomeHealthHealth

Prof.Prof.ServicesServices

Prof.Prof.ServicesServices ClinicsClinicsClinicsClinics Psych/Psych/

RehabRehabPsych/Psych/RehabRehab

PreventiveHealth Ed.Wellness

PreventiveHealth Ed.Wellness

Emerging Health NetworkEmerging Health NetworkClinical ObjectivesClinical Objectives

Integrate data from all provider settings in the health system.

Follow patient across the continuum of care.

Provide clinicians with a consistent view of patient status regardless of where services are performed.

Emerging Health NetworkEmerging Health NetworkFinancial ObjectivesFinancial Objectives

Allow direct contracting with employers/capitation.

Track health care and costs throughout an enterprise.

Provide tools to manage a population. Provide utilization data to make informed

decisions. Improved clinical care. Improved financial viability.

PatientPatient

Private Insurance

Private Insurance

HomeMedical

EquipmentProvider

HomeMedical

EquipmentProvider

Home I.V. ProviderPharmacy

Home I.V. ProviderPharmacy

Medicare

Medicaid

Medicare

Medicaid

Home Health Provider

• Skilled Nursing

• Non-Skilled Nursing

• Rehab Therapies

Home Health Provider

• Skilled Nursing

• Non-Skilled Nursing

• Rehab Therapies

Traditional Homecare ModelTraditional Homecare Model

Home Health

Home I.V. Provider

HME

Home Health

Home I.V. Provider

HME

Today’s Homecare ModelToday’s Homecare Model

Skilled Nursing

Non-Skilled Nursing

Pharmacy

HME

Rehab Therapies

Skilled Nursing

Non-Skilled Nursing

Pharmacy

HME

Rehab Therapies

Self-Insured

HMOs

PPOs

Medicare

Medicaid

Private Insurance

Self-Insured

HMOs

PPOs

Medicare

Medicaid

Private Insurance

PopulationPopulation

PPS

Impact on the Homecare Impact on the Homecare ProviderProvider

Managed competition. Increased shift of patient

population from acute care. Industry-wide consolidation of

providers and vendors. Demonstrated outcomes require

automated data collection. Reduction in reimbursement for

services provided.

Impact On Homecare Impact On Homecare OrganizationsOrganizations New Clinical ExpectationsNew Clinical Expectations

Clinical skills to assess and treat higher acuity patients.

Homecare manager becomes case manager. Point of service data collection for outcomes.

Impact On Homecare Impact On Homecare OrganizationsOrganizations New Information SystemNew Information System

Clinical outcome data tracking. Practice guidelines formation and

tracking. Customer satisfaction tools. Provider profiling. Provider performance.

KEY TO SUCCESSKEY TO SUCCESS

Clinical excellence

Care DesignCare Design

Problems/

Outcomes

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

Problems/

Outcomes

Interventions/

Activities

Care DesignCare Design

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

Problems/

Outcomes

Interventions/

ActivitiesDiagnosis ICD-9

Care DesignCare Design

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

Problems/

Outcomes

Interventions/

Activities

Level of Severity /

Disease

Care DesignCare Design

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

Diagnosis ICD-9

BENCHMARK PATHWAY

Physical

Variables

Non-Physical

Variables

Level of Severity /

Disease

The Care Design/Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

The Care Design/Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.

Diagnosis ICD-9

Problems/

Outcomes

Interventions/

Activities

Level of Severity /

Disease

Care DesignCare Design

Diagnosis ICD-9

Care DesignCare DesignBenchmarkBenchmark

Purpose: To Establish a Standard of Care As It Relates to a

Specific Diagnosis, Level of Severity and Treatment.

Actual - Services/Treatments/Supplies/Drugs Actually Used in Total Treatment Plan.

Prescribed - Services/Treatments/Supplies/Drugs Prescribed by Attending Physician.

Benchmark - Established Norm of Services Treatments/ Supplies/Drugs Based on Diagnosis and Level of Severity/Disease State.

ActualActualActualActual PrescribedPrescribedPrescribedPrescribed

BenchmarkBenchmarkBenchmarkBenchmark

IdealIdealIdealIdeal

Ultimate GoalUltimate Goal

McKesson HBOC Pathways McKesson HBOC Pathways Homecare - Unique FeaturesHomecare - Unique Features

Complete solution-all homecare service lines. Integration with McKesson HBOC products. Integration of financial and clinical homecare applications

and data. Integration of data from all disciplines in the homecare

arena promoting automated collaborative care. Discrete/structured data capture. Intuitive GUI supporting both non-technical and

experienced end users. Designed by experienced homecare clinicians.

McKesson Pathways McKesson Pathways Homecare - Unique FeaturesHomecare - Unique Features

Automation of documentation process Assessment/vitals MAR and IV administration Clinical pathways and care plans All HCFA forms become by product of collected information

Severity indexing tool Weighted questions

Starter kit to build care designs/care plans Sample interdisciplinary clinical pathways Library of treatment interventions, outcome goals, and staging

questions Library of assessment data

McKesson HBOC Pathways McKesson HBOC Pathways Homecare - BenefitsHomecare - Benefits

Clinical benefits. Reduction in time generating appropriate paperwork (i.E.

HCFA 485). Access to current and historical organized patient

information . Increased communication through automated collaborative

care. Ability to measure patient specific clinical outcomes. Ability to develop and customize interdisciplinary care

designs and care plans.

Pathways HomecarePathways HomecareTechnical RequirementsTechnical Requirements

POC support Store and forward Laptops

Connectivity Dial-up via a modem

Hardware/operating system/RDBMS

Sequeal server