Nurses have an extremely important healthcare

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1 FEATURE: NURSING INFORMATICS Nursig Termiology Documetatio of Quality Ooutcomes By LuA Whitteburg, RN, FNP Keywords Quality, iformatio systems, ursig termiology, atomic data, structured data, coded data, ursig documetatio, outcomes maagemet. Abstract Recetly, govermet ad healthcare providers have recogized the tremedous value ad importace of advacig the use of electroic healthcare iformatio systems. Without questio, the issue of quality has become a focus of cocer for cosumers, politicias ad healthcare providers ad a priority for healthcare orgaizatios i the 21 st cetury. The ursig professio through the America Nurses Associatio has log recogized the eed for quatitative evidece to measure the relatioship of documetatio to the impact o patiet care. The followig article discusses the ability of electroic healthcare iformatio systems to collect ursig data usig ursig termiology for care quality ad outcome maagemet. The purpose is to iform iformatics professioals of a immediate eed to coect electroic healthcare iformatio systems with a stadard, cocept-based, atomic-level, coded ursig termiology readily available i the public domai for the logitudial aalyses of the cotiuity of care ad of the urses cotributio to healthcare quality. Nurses have a extremely importat healthcare goal which is to improve the health status of idividuals ad prevet prospective health problems. 2,6,22 However, a stadard ursig termiology for the coded, atomic-level documetatio of the complexities of patiet coditios ad ursig care i electroic healthcare iformatio systems are missig. O Kae et al. 13 oted the fudametal buildig block of ay high-performace health system is reliable iformatio about the effectiveess of care. This article will discuss a solutio to eable electroic healthcare iformatio systems to collect ursig documetatio at a atomic data level usig a ursig termiology recogized by the America Nurses Associatio (ANA) readily available i the public domai today for quality outcomes maagemet. NURSING INFORMATICS ROLE IN HEALTHCARE Sice 2000, the Federal policy has bee to promote improvemets i healthcare delivery performace i order to obtai trasparecy i the quality of healthcare. The Office of Maagemet & Budget (OMB) states the US models of care are ot aliged with the objective to provide the right care to the right patiet at the right time. Accordig to Kae & Siegrist 8 ursig care cosumes 30 percet of total hospital operatig budgets yet the impact of ursig diagoses, itervetios ad outcomes o patiet care is ivisible to support quality trasparecy. Ad, the focus o quality trasparecy is expected to icrease expoetially as the Ceters for Medicare ad Medicaid Services implemets the opay diagoses for which urses have major patiet care resposibilities. Nursig is ow discoverig that electroic healthcare iformatio systems are icreasigly less likely to be a direct out- volume 23 / umber 3 Summer 2009 jhim 51

2 growth of the traditioal medical record 11,21 ad a stadard ursig framework for coded, structured documetatio is eeded to operatioalize ursig s cotributio to care cotiuity ad quality outcomes. OPERATIONALIZING NURSING TERMINOLOGY Oe of the most frequetly applied methods for evaluatig the successful implemetatio of electroic healthcare iformatio systems has bee to access urses attitudes toward computer use. 4 Nurses were assumed to have egative attitudes toward computers, thus eedig assistace with techology use. More recet studies have revealed that urses o loger have a egative attitude toward computers. 9 May authors have idetified that the success of a techology iovatio relies o the idividual s decisio to adopt the iovatio (perceptio attributes: relative advatage, complexity ad compatibility). 15 The impact of iovatio, as applied to the adoptio or rejectio, has importat implicatios i developig effective strategies for the visibility of ursig i electroic healthcare iformatio systems. 9 The objective of ursig iformatics is to improve ursig practice through the creative use of techology. Ad, there appears to be a complimetary relatioship betwee the cocept of iovatio ad ursig iformatics. However, a iovatio usually has at least some degree of beefit for adopters. Ad, while the beefit may ot always be very clear-cut, the iteded adopters are seldom certai that a iovatio represets a superior alterative to the previous practice that it might replace. 15 While the cocept of iovatio establishes the coditios for techology adoptio, say for example, a stadard, cocept-based, atomic-level, coded ursig termiology for use i ursig practice, a urse may cosider the iovatio a critical factor i patiet safety. Therefore, there may also be a iterdepedece betwee the iovatio of the operatioalizig of a ursig termiology, care quality, ad patiet safety. IMPLICATIONS FOR THE HEALTHCARE ENVIRONMENT Occasioally, oe hears the commet that limits the implemetatio of a ursig termiology - the belief that the cocept may oversimplify a complex reality. Yet, the structured represetatio of ursig documetatio i electroic healthcare iformatio systems is a iovatio of critical importace. Today, the formatio of a commo electroic ursig laguage to describe, aalyze ad classify the ursig experiece for the compariso ad retrieval of ursig data across systems ad orgaizatios is a professioal imperative. The Natioal Committee o Vital ad Health Statistics (NCVHS), as a advisory body to the Departmet of Health ad Huma Services for atioal health iformatio policy, is icreasig ivolved i supportig ew techologies (iovatio) cocered with stadards for the retrieval ad sharig of health iformatio i healthcare iformatio systems. While the NCVHS charter is to foster collaboratio for volutary health data iteroperability, fudig is provided through the Agecy for Healthcare Research ad Quality (AHRQ) to accelerate the developmet of public ad private sector cosesus aroud key data stadards. I the 21 st cetury, techology is a meas to a ed; ursig must lear to maipulate the techology i the proper maer. The power of a ursig termiology for codig ursig documetatio was developed from a cliical observace of the eed for atomic level data i ursig practice i electroic healthcare iformatio systems. Data at the atomic level represets a basic data form, essetially the smallest meaigful uit i ay system. Ay data below the atomic level does ot provide meaigful aalysis. The clear defiitio of a atomic level data makes the logical desig of ursig termiology possible. Ad, ay imprecise data defiitios, such as icludig a mixture of foci i ursig termiology is a threat to ay system architecture desig icludig up to ad icludig the processes that retur data to reports usig coded data. There is a coded, structured ursig termiology i the public domai, the Cliical Care Classificatio System (CCC), readily available today, that starts at the lowest, most atomic level of data providig the aswer to what is the atomic level data required by the urse to documet the essece of care. The power of the atomic level data is the clarity ecessary for operatioalizig the ursig process: 1. Assessmet; 2. Diagosis; 3. Outcome Idetificatio; 4. Plaig; 5. Implemetatio; ad 6. Evaluatio for the electroic ursig documetatio of cliical care based o discrete cocepts. The sigificace of the Cliical Care Classificatio System (CCC) is that this ursig termiology completes the missig lik eeded to address ursig cotributio to healthcare quality. The CCC provides the data eeded to address ursig documetatio usig a structured, coded termiology. Thus far, ursig has coducted separate research studies usig differet variables ad/or methods without a stadardized termiology resultig i differet fidigs that caot be compared. If a stadardized ursig termiology were used, studies could compare fidigs across populatio groups ad settigs. For example, the CCC System has bee show to be valid for ursig documetatio i differet acute-care hospital settigs by several differet researchers such as Holzemer 9 ad Moss, Damrogsak ad Gallichio. 12 Further, sice the Cliical Care Classificatio System is available as a atioal ursig stadard, the CCC may be used to support ursig practice ad geerate comparable iformatio across healthcare settigs for the care process. The Cliical Care Classificatio System is structured for computer processig eablig research to be coducted o complex ursig cocepts idividually as well as aggregated for other aalyses. The computable structure of the CCC allows researchers to determie the cotributio of ursig care to quality, as well as determie care eeds (resources) workload (productivity), ad outcomes. 20 The Cliical Care Classificatio System is a coded ursig termiology desiged to electroically documet ursig practice ad cosists of two iterrelated termiologies: the CCC of Nursig Diagoses ad Outcomes ad the CCC of Nursig Itervetios ad Actio Types both of which are classified by 21 Care Compoets. The Cliical Care Classificatio System was developed from a research study coducted by Virgiia K. Saba, EdD, RN, FAAN, FACMI ad a research team through a cotract with the Health Care Fiacig Agecy (HCFA), curretly the Ceters for Medicare ad Medicaid Services (CMS). The project collected live patiet data from more tha 8,900 patiet records repre- 52 jhim Summer 2009 volume 23 / Number 3

3 setig approximately 800 healthcare facilities. Dr. Saba ad a research team spet more tha a year aalyzig ad codig the textual phrases for approximately 45,000 phrases represetig ursig diagoses ad/or patiet problems ad 70,000 phrases depictig ursig services, itervetios, actio types, ad other activities. By usig key- word-sorts to aalyze the phrases, the research team distilled their fidigs ito essece of ursig care cocepts, ad developed the CCC System. 18 As stated above, the Cliical Care Classificatio System was the first amed atioal ursig iteroperability stadard accepted for iteroperability implemetatio or exchage of iformatio i the Electroic Health Record. The Cliical Care Classificatio System was selected because the termiology is: (a) is based o research data, (b) foud to be usable i all healthcare settigs, (c) cotais atomic-level data cocepts each with a uique defiitio ad idetificatio umber, (d) requires o licesig fee (e.g., dowloadable without disclosure ad immediately available (icludig codes ad table structures) i the public domai, (e) itegrated i Metathesaurus of the Uified Medical Laguage System (UMLS) ad the Systematized Nomeclature of Medicie-Cliical Terms (SNOMED CT ), (f ) is desiged for electroic healthcare iformatio systems, ad (g) has several other characteristics of a termiology as defied i the Desiderata for cotrolled medical vocabularies i the twety-first cetury. 3 The Cliical Care Classificatio System is recogized by the America Nurses Associatio as a comprehesive, coded, ursig termiology that ca be used to support the documetig of ursig practice via the Electroic Health Record. I additio, the CCC provides the framework ad cocepts for idetifyig the essece of ursig care which refers to the treatmet of the patiet s presetig problem to idetify the ursig diagosis based o the evaluatio of the assessed sigs ad symptoms, followed by the selectio of the ursig itervetios ad actios eeded to treat the patiet to achieve a outcome. 19 NURSING DIAGNOSES AND OUTCOMES The Cliical Care Classificatio System, versio 2.0, cosists of 182 CCC Nursig Diagosis cocepts (59 major ad 123 subcategories) that represet the assessed sigs ad symptoms of the patiet problems requirig cliical care primarily by urses. The Nursig Diagoses forms the basis for 546 Expected/Actual Nursig Outcomes (See for the list of CCC diagoses. The Nursig Outcomes represet the 182 Nursig Diagoses each with oe of three possible outcomes (Improved, Stabilized or Deteriorated). The Nursig Diagoses provide the basis for the Actio Types ad Nursig Itervetios. 19 INTERVENTIONS AND ACTION TYPES The CCC System, versio 2.0, cosists of 198 CCC Nursig Itervetios ad 4 Actio Types (Assess, Perform, Teach ad Maage), totallig 792 Nursig Itervetios Actios that are used to documet the essece of ursig care provided to a patiet. The 198 CCC Nursig Itervetios are always modified by oe of the 4 Actio Types creatig a two level hierarchal classificatio structure. A Nursig Itervetio is defied as a sigle ursig actio desiged to achieve a outcomes for a ursig or medical diagosis for which the urse is accoutable. 18, 19 There are four CCC Actio Types were derived from the frequecies aalyzed i the research study of 70,000 textual phrases described above. I aalyzig ursig services statemets the researchers oted that differet services were reported multiple times to represet two differet aspects of care - the actual service ad a actio type. By usig permuted keyword sorts several Sice 2000, the Federal policy has bee to promote improvemets i healthcare delivery performace i order to obtai trasparecy i the quality of healthcare. thousad ursig services statemets were sorted ad clustered by computer i two ways, (a) by ursig service cocept ad (b) by actio type qualifier/modifier. Computer rus were coducted repeatedly util like core cocepts ad like actio types were foud to be defiable, logical, ad usable. For example: Istruct Woud Care ad Teach Woud Care were clustered with the commo core cocept Woud Care ad Istruct ad Teach with a commo actio type meaig Teach. 19 As a result the research team created four differet Actio Types: (a) Assess or Moitor, (b) Perform or Provide Direct Care, (c) Teach or Istruct or (d) Maage or Refer. Each of the 4 Actio Types were also foud to qualify/modify each of the 198 CCC Nursig Itervetios resultig i 792 CCC Nursig Itervetio Actios. The Itervetios ad Actio Types were the tested by codig a sample of statemets to determie reliability. This process was repeated util there was agreemet amog the codig staff of three graduate ursig studets who served as Research Assistats ad the Project Maager. Further, the strategy of codig the core Nursig Itervetio ad Actio Type separately was viewed as a meas of determiig the core cocepts, simplifyig the codig of the care data, ad processig by computer. Ultimately, the Cliical Care Classificatio System (CCC) is a omeclature of discrete atomic-level data elemets about the ursig process that ecompasses ursig assessmet, diagosis, itervetio, actios ad actual ad expected outcomes. The CCC System is a electroic healthcare iformatio system stadard to idetify the cotributio of ursig to patiet outcomes for improved healthcare services. The coded ursig diagoses, itervetios ad outcomes immediately dowloadable ad readily available for use by orgaizatios iterested i describig ad commuicatig the electroic documetatio of ursig practice today. The beefits of Cliical Care Classificatio System (CCC) data elemets are that iformatio techology aalyst, healthcare maagers, ad ursig are able to use the commo uits of data to use a termiology i the public domai for health iformatio systems ad applicatios as well as realize a sigificat ad immediate retur o ivestmet for IT system products. Usig the CCC ursig termiology should: volume 23 / umber 3 Summer 2009 jhim 53

4 Accelerated electroic health iformatio system software developmet. Icrease employee productivity (stadardized documetatio). Provide stadardized cosistet health data for itervetios ad research. Provide re-usable health data for cross-orgaizatio comparisos. Reduce healthcare cost from improved, documeted outcomes by itervetio. Reduce level of effort i uecessary computer system data elemet developmet. The Cliical Care Classificatio System (CCC) is the oly ursig termiology specifically developed for computerizatio e.g. electroic healthcare iformatio systems ad computer-based patiet records (CPR) from research which collected live patiet care data. The CCC, followig the six steps of the ursig process: 1. Assessmet; 2. Diagosis; 3. Outcome Idetificatio; 4. Plaig; 5. Implemetatio; ad 6. Evaluatio specifically liks ursig diagoses to ursig itervetios to ursig outcomes. Ad, i additio to the beig itegrated i the Metathesaurus of the Uified Medical Laguage System (UMLS) of the Natioal Library of Medicie (NLM ad SNOMED CT, the CCC is also itegrated i the Cumulative Idex to Nursig & Allied Health Literature (CINAHL) ad approved as a termiology by the America Natioal Stadards Istitute (ANSI) Stadard Developmet Orgaizatio (SDO) Health Level Seve (HL7 ). The CCC Nursig Diagoses ad Outcomes are used i the Cliical LOINC System for documetig diagoses outcomes ad the CCC has bee tested as a iteratioal ursig stadard based o the A Itegrated Referece Termiology Model for Nursig approved by the Iteratioal Stadards Orgaizatio (TC-215) i October The CCC is cosidered a cocept termiology ad has source files olie so public ad private orgaizatios may harmoize ursig iformatio formats for the cross orgaizatioal sharig of iformatio. The CCC was also oe of the cotributed termiologies used as the basis for the origial alpha versio of the Iteratioal Classificatio of Nursig Practice (ICNP ) developed by the Iteratioal Coucil of Nurses (ICN). ICNP has sice bee revised several times to correct the redudacy ad the ambiguity of terms ad provide avigatioal hierarchies for easier use. At this time, the ICNP has had very limited use i the Uited States. NEXT STEPS The Agecy for Healthcare Research ad Quality (AHRQ) has fuded idividuals across the coutry examiig iformatio systems to improve quality of care. A demostratio project to test the perceptio of iovatio o the adoptio of the 2007 HHS atioal ursig laguage for assessmets, diagoses, itervetios ad outcomes is immediately feasible give that the use of stadardized ursig laguage will improve the data capture of the delivery of cliical ursig care ad icrease the visibility of the cotributio of ursig practice through the use of iformatio systems. Samples of curretly fuded AHRQ projects iclude: a) Title: Electroic Records to Improve Care for Childre, Primary Ivestigator: Richard Shiffma, State: CT ad b) Title: Impact of Health Iformatio Techology o Cliical Care, Primary Ivestigator: Joh Hsu, State: CA. Proposals are posted o the AHRQ website at ahrq.gov/portal Nurses are expected to coordiate a patiet s care, yet there is a great deal of missig data i primary care settigs. 1 The circumstaces appear to be that the umber of patiets is icreasig yet Ultimately, the Cliical Care Classificatio System is a omeclature of discrete atomiclevel data elemets about the ursig process that ecompasses ursig assessmet, diagosis, itervetio, actios ad actual ad expected outcomes. the accuracy of the patiet data collected is decreased. This could be the result of umerous costraits icludig reimbursemet or performace demads; so, further study to explore the pheomea is eeded. The ursig professio through the America Nurses Associatio has log recogized the eed for quatitative evidece to measure the relatioship of cliical documetatio to the impact o patiet care, ad supply a scietific foudatio for evideced-based practice. With the itroductio of electroic healthcare iformatio systems, healthcare orgaizatios have the ability to modify iformatio systems to collect ursig documetatio data with specificity ad determie care quality ad outcome maagemet data. CONCLUSION The purpose of this article was to iform iformatics professioals of a immediate eed to coect electroic healthcare iformatio systems with a stadard, cocept-based, atomiclevel, coded ursig termiology for the logitudial aalyses of the cotiuity of care ad of the urses cotributio to healthcare quality. Nursig care may be the most critical factor i a patiet s treatmet ad recovery 5 ad uderstadig the impact of care o patiet outcomes may be the key to improvig quality i today s healthcare system. The computable structure of the Cliical Care Classificatio System (CCC) already i the public domai promotes system upgrades of existig electroic healthcare iformatio systems. The system architecture of the CCC offers a retur o ivestmet with discrete, atomic-level data o the impact of ursig care to care quality, as well as productivity (workload), resources (staffig), ad outcomes maagemet. The objective of ursig iformatics is to improve ursig practice through the creative use of techology. This article examied the theory of iovatio as a model-drive orgaizig framework for operatioalizig of ursig termiology to documet ursig practice ad ursig iformatics research with the ratioale beig the strog 54 jhim Summer 2009 volume 23 / Number 3

5 iterdepedece ad complimetary relatioship betwee the cocept of iovatio ad ursig iformatics. I coclusio, the pivotal role of urses, i healthcare quality by perceptio clearly highlights the eed for more quatitative data research ad iformatics work i this importat area. JHIM LuA Whitteburg, RN, FNP, received a MSN from Marymout Uiversity. She is a Nurse Practitioer, Board Certified i Family Practice ad Nursig Iformatics. She is curretly a PhD studet at George Maso Uiversity ad Health Iformatics Cosultat with the Computer Scieces Corporatio. Refereces 1. Berer ES, Moss J. (2005). Iformatics challeges for the impedig Patiet iformatio explosio. JAMIA. 12;(6): Chiasso M, Reddy M, Kapla B, Davidso E. (2007). Expadig multidiscipliary approaches to health care iformatio techologies: What do iformatio systems offer medical iformatics? It J Med Iform. 76: Cimio JJ. (1998). Desiderata for cotrolled medical vocabularies i the twety-first cetury. Methods of Iformatio i Medicie. 37; Deis KE, Sweeey PN, McDoald LP, Morse NA. (1993). Poit of care techology: impact o people ad paperwork. Nurs Eco. 11;(4): Gordo S. (2005). Nursig Agaist the Odds: How Health Care Cost Cuttig, Media Stereotypes, ad Medical Hubris Udermie Nurses ad Patiet Care. Ithaca, New York, Corell Uiversity Press. 6. Hassol A, Walker JM, Kidder D, Rokita K, Youg D, Pierdo S, et al. (2004). Patiet experieces ad attitudes about access to a Patiet Electroic Healthcare Record ad liked Web messagig. JAMIA. 11;(6): Holzemer WI, Hery SB, Dawso C, Sousa K, Bai C, Hsieh SF. (1999). A evaluatio of the utility of the Home Health Care Classificatio for categorizig patiet problems ad ursig itervetios for the hospital settig. I U. Gerli, M. Tallberg, P. Waiwright (Eds.), NI-99: Nursig Iformatics: The Impact of Nursig Kowledge o Health Care Iformatics (pp ). Stockholm, Swede: IOS Press. 8. Kae NM, Siegrist RB. (Dec. 15, 2007). Uderstadig risig hospital ipatiet costs: key compoets of costs o the impact of poor quality. I L. Uruh, & S. Hassmiller, S. Legislative: Ecoomics of Nursig Ivitatioal Coferece Addresses Quality ad Paymet Issues i Nursig Care. OJIN: The Olie Joural of Issues i Nursig. 13: Lee TT. (2004). Nurses adoptio of techology: Applicatio of Rogers iovatio diffusio model. Applied Nursig Research. 17;(4): Public stadards ad patiet cotrol: How to keep Electroic Medical Records accessible but private. British Medical Joural. 322;(3): Moe A, Gregory J, Brea PF. (2007). Cross cultural factors ecessary to eable desig of flexible cosumer health iformatics systems (CHIS). It J Med Iform. 76: Moss J, Damrogsak M, Gallichio.(2005). Represetig critical care data usig the Cliical Care Classificatio. I C.P. Friedma, J. Ash, & Tarcy-Horoch (Eds.), Proceedigs: Aual Symposium. Washigto, DC: AMIA (CD-ROM) 13. O Kae M, Corriga J, Foote SM, Tuis SR, Isham GJ, Nichols LM, et al. (2008). Crossroads i Quality. Health Aff. 27(3): Rogers EM. (1976). New product adoptio ad diffusio. Joural of Cosumer Research. 2(12): Rogers EM. (1995). Diffusio of Iovatios (4th ed.). New York: the Free Press. 16. Saba VK. (1992). Diagoses ad Itervetios. Carig Magazie. 3: Saba VK. (2005). Cliical Care Classificatio (CCC) of Nursig Itervetios. Retrieved December 15, 2005, from Saba VK. (2005) Cliical Care Classificatio (CCC) of Nursig Itervetios. Retrieved December 15, 2005, from Saba VK. (2007) Cliical Care Classificatio (CCC) System maual: A Guide to Nursig Documetatio. New York: Spriger Publishig. 20. Saba VK, Taylor SL. (2007). Movig past theory: Use of a stadardized coded ursig termiology to ehace ursig visibility. Computers i Nursig. 25(6): Smolij K, Du K. (2006). Patiet health iformatio maagemet: Searchig for the right model. Perspectives ad Health Iformatio Maagemet. 2006(3): Uruh KT, Pratt W. (2004). Patiets as actors: the Patiet s role i detectig, prevetig, ad recoverig from medical errors. JAMIA. 11(6): volume 23 / umber 3 Summer 2009 jhim 55