Integration of Nursing Informatics, Nursing Classification Systems, and Nursing Practice (Nur 603)

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Integration of Nursing Informatics, Nursing
Classification Systems, and Nursing Practice(Nur
603)

• Presenter
• Russell McGuire, MSN, RN
• Director of Clinical Services, DHS
• Appalachian Regional Healthcare, Inc.

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Appalachian Regional Healthcare

• 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

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ARH System Center Home Services

• 32,000 visits in 1969
• Over 450,000 for FY 97-98
• Services provided in 2 state region
• Eastern Kentucky
• Southern west Virginia

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Nursing Informatics
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Nursing 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).

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Nursing 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.

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Conceptual Framework
Nursing Process
Data
Information
Knowledge
(raw facts)
(interpreted facts)
(synthesized information)
Atomic level
Synthesis
Information and Communication Technology
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Nursing Classification Systems
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Reasons for Classification System Development

• 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)
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Relevant 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.

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Relevant 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 NLNs
  Council for Nursing Informatics.

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History

• 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 ANAs Social Policy Statement - Nursing is
  the diagnosis and treatment of human responses to
  actual or potential health problems.

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History

• 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.

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History

• 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.

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History

• 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.

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History

• 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.

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Rationale Next Generation Nursing Information
Systems Essential Characteristics for
Professional 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.

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Rationale

• 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.

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Users Data/Information
Scope
World health officials
General health status and
Worldwide Policy makers,
Researchers
health-related needs
Data Lawmakers
of individual
nations.
ABSTRACTED, SUMMARIZED, AGGREGATED
Policy makers
Trends in incidence, prevalence,
Nationwide
Lawmakers, researchers
outcomes, and costs by region, by
Data Insures

diagnosis, by type of agency.
ABSTRACTED, SUMMARIZED, AGGREGATED
Analysts, researchers,
Comparisons of treatments, outcomes,
Community/ Quality management,
and costs by locality and by
agency.
Region-wide Public health officials
Incidence and prevalence of diagnosis by region.
Data
ABSTRACTED, SUMMARIZED, AGGREGATED
Administrators,
Costs of care by category of patient.
Agency-wide Researchers,
Accreditors Number of patients admitted with
specific diagnosis. Data Quality
managers Volume of tests,
procedures, interventions, outcomes.
ABSTRACTED, SUMMARIZED, AGGREGATED
Caregivers
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
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Rationale

• 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.

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Where is all this Leading?Unified 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

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Where Is All This Leading?Unified 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.

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Where Is All This Leading?Unified 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.

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Where Is All This Leading?Unified 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.

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Where Is All This Leading?Unified 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.

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Are you
NANDA, NIC,
NOC, Impaired ?
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Integration Into Nursing Practice
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ARH Experience With Nursing Classification 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.

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ARH Experience With Nursing Classification 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).

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ARH Experience With Nursing Classification 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.

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ARH Experience With Nursing Classification
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.

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ARH Experience With Nursing Classification
Systems NANDA

• Advantages.
• Comprehensive listing of nursing diagnoses.
• National and international recognition.
• Disadvantages.
• Does not address specific interventions or
  outcomes.

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ARH Experience With Nursing Classification
Systems NIC

• NIC - nursing intervention project (Iowa project.
• Features.
• 433 documented, researched nursing interventions.

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ARH Experience With Nursing Classification
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.

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ARH Experience With Nursing Classification
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

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ARH Experience With Nursing Classification
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.

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Extended Health Enterprise Model
Managed Care
Employers
Population
Network
Insurers
Regulatory Agencies
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Emerging Health NetworkClinical 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.

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Emerging Health NetworkFinancial 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.

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Traditional Homecare Model
Home Medical Equipment Provider
Home I.V. ProviderPharmacy

• Home Health Provider
• Skilled Nursing
• Non-Skilled Nursing
• Rehab Therapies

Patient
Private Insurance
Medicare Medicaid
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Todays Homecare Model
Home Health Home I.V. Provider HME
Population
Skilled Nursing Non-Skilled Nursing Pharmacy HME R
ehab Therapies
PPS
Self-Insured HMOs PPOs Medicare Medicaid Private
Insurance
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Impact on the Homecare Provider

• 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.

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Impact On Homecare Organizations New
Clinical Expectations

• Clinical skills to assess and treat higher acuity
  patients.
• Homecare manager becomes case manager.
• Point of service data collection for outcomes.

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Impact On Homecare Organizations New
Information System

• Clinical outcome data tracking.
• Practice guidelines formation and tracking.
• Customer satisfaction tools.
• Provider profiling.
• Provider performance.

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KEY TO SUCCESS

• Clinical excellence

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Care Design
Problems/
Outcomes
The Care Design/ Pathway Should Represent a
Benchmark of Care Which Can Be Adapted to
Specific Practices or Demographics.
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Care Design
Problems/
Interventions/
Outcomes
Activities
The Care Design/ Pathway Should Represent a
Benchmark of Care Which Can Be Adapted to
Specific Practices or Demographics.
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Care Design
Problems/
Interventions/
Diagnosis ICD-9
Outcomes
Activities
The Care Design/ Pathway Should Represent a
Benchmark of Care Which Can Be Adapted to
Specific Practices or Demographics.
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Care Design
Level of
Problems/
Interventions/
Diagnosis ICD-9
Severity /
Outcomes
Activities
Disease
The Care Design/ Pathway Should Represent a
Benchmark of Care Which Can Be Adapted to
Specific Practices or Demographics.
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Care Design
Level of
Level of
Physical
Non-Physical
Problems/
Interventions/
Diagnosis ICD-9
Diagnosis ICD-9
Severity /
Severity /
Variables
Variables
Outcomes
Activities
Disease
Disease
BENCHMARK PATHWAY
The Care Design/Pathway Should Represent a
Benchmark of Care Which Can Be Adapted to
Specific Practices or Demographics.
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Care DesignBenchmark

• Purpose
• To Establish a Standard of Care As It Relates
  to a Specific Diagnosis, Level of Severity and
  Treatment.

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Ultimate Goal
Actual
Prescribed
Ideal
Benchmark

• 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.

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McKesson HBOC Pathways Homecare - 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.

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McKesson Pathways Homecare - 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

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McKesson HBOC Pathways Homecare - 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.

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Pathways HomecareTechnical Requirements

• POC support
• Store and forward
• Laptops
• Connectivity
• Dial-up via a modem
• Hardware/operating system/RDBMS
• Sequeal server