Standardized Terminologies, Information Technology, and the Real World Karen S. Martin, RN, MSN, FAAN Sue Moorhead, RN, PhD Kathy Lesh, RN BC, EdM, MS Wheel of Fortune Objectives Summarize ANA recognized standardized terminologies. Identify implementation experiences. Describe strengths, barriers, and strategies when transforming data. Summarize the relationship of standards and interoperability to users and vendors. Trendssssss! Automation Clinical data and information Outcomes management Standardization
ANA Recognized Terminologies & Data Element Sets Omaha System NANDA International NIC NOC CCC Perioperative Nursing Data Set Nursing Management Minimum Data Set SNOMED CT Nursing Minimum Data Set ABC Codes ICNP LOINC Successful Action Plans: Partnerships with Users, Vendors, & IT Planning Orientation Implementation
Problem Classification Scheme Domain Problem Modifier Sign/Symptom Problem Classification Scheme Assessment Home Care Clients Neuro-musculo-skeletal function Medication regimen Skin Circulation Pain Respiration Health care supervision Intervention Scheme Category Target Client Specific Information
Intervention Scheme Care Provided Home Care Clients Problem Rating Scale for Outcomes Knowledge Behavior Status Problem Rating Scale for Outcomes Outcome Trends Courtesy of KA Monsen, Washington County PHE, Stillwater, MN 1 Change in Ratings 0.8 0.6 0.4 0.2 0 0-100 101-205 206-412 413-1,183 Length of Services in Days Knowledge Behavior Status
Omaha System Implementation Literature Website Case Studies Workshops Omaha System International Conferences Vendor Demonstrations/Discussions Contacts/Visits Successful Action Plans: Partnerships with Users, Vendors, & IT Planning Orientation Implementation Nursing Knowledge Diagnoses Classification Interventions Classification Outcomes Classification Clinical Decision Making Choice Choice Choice
Nursing Diagnosis Definition: A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. 188 diagnoses developed (2007 edition) Structure Concept Definition Defining Characteristics Related Factors or Risk Factors Nursing Interventions Classification Definition: Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes. 542 interventions Structure Label name Definition A list of activities References Nursing Outcomes Classification Definition: An individual, family or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention. 385 outcomes Structure Label name Definition Indicators Measurement scale(s)
NNN Linkages Helpful for implementation Links outcomes to Dx and suggests possible interventions Provides case studies Implementation NIC Core interventions identified by nursing specialty Used for competency evaluation Used determine cost of nursing care by using time estimates Used to determine interventions/activities that can be delegated Implementation NOC Can determine outcomes of care using rating scales Ability to set target rating Uses reference person Define parameters for discharge Evaluate care for a group of patients over time
Change Post Intervention Outcome N Average Average Average Base Follow Change Self-Mutilation Restraint 06 2.17 4.33 2.17 Respiratory Status: Gas Exchange 31 2.94 4.13 1.19 Mobility Level 53 2.47 3.62 1.15 Effectiveness Research Collecting standardized nursing data facilitates effectiveness research to enhance quality and improve patient outcomes CNPII Committee for Nursing Practice Information Infrastructure Related to nursing practice information infrastructure, the Committee s core purpose is to: 1. Serve as the primary authority for the ANA on the information infrastructure necessary to support nursing practice. 2. Influence health policy related to healthcare information technology at the international, national, state, local levels. 3. Encourage the continued development, maintenance, and integration of ANA recognized nursing terminologies. 4. Inform healthcare organizations of the need to capture standardized nursing data that expresses the presence and contribution of nursing, nursing research, and evidence based practice. Mission Statement: The CNPII seeks to ensure that clinical information systems include an interoperable infrastructure that captures the data and information to clearly demonstrate the presence and value of nursing practice.
ANA Recognized Terminologies & Data Element Sets ABC Codes CCC ICNP LOINC NANDA International NIC NOC Omaha System Perioperative Nursing Data Set SNOMED CT Nursing Management Minimum Data Set Nursing Minimum Data Set Nursing Data Element Sets NMMDS Developed for All Settings Administrative Nursing Data Elements 18 NMDS Developed for All Nursing Clinical Data Elements 16 Point of Care Terminologies AKA Interface Terminologies Terminology Where Developed Content CCC All Nursing Care D, I, O ICNP All Nursing D, I, O NANDA All Nursing D NIC All Nursing I NOC All Nursing O Omaha System HC, PH, Com D, I, O PNDS Peri operative D, I, O
Multidisciplinary Terminologies Terminology Where Developed Content ABC Nursing & Other I LOINC Nursing & Other O & Assess SNOMED CT Nursing & Other D, I, O Levels of Automated System Wisdom Knowledge Expert System Information Decision Support System Information System Data (2007 Draft). Nursing informatics: Scope and standards of practice Continuum of Understanding ANA (2007 Draft). Nursing informatics: Scope and standards of practice.
But It s Not Easy We Are Not Practicing in a Vacuum ANCC, AAN, CNPII, CNE, EHR TG, NIDSEC, NDNQI, Nursing informatics: Scope and Standards of Practice, NMDS, NMMDS, CCC, ICNP, NANDA, NOC, NIC, PCDS, PNDS, Omaha System, ABC, LOINC, SNOMED CT, HITSP, CCHIT, AHIC, IHE, NCVHS, NHIN, ONC, ANI, HIMSS, NI WG, AMIA, CARING, CIS WG, NINR, TIGER, NCVHS, Vanderbilt Summit, ICN, HL7, IHTSDO, ANSI, ISO, ACENDIO, CEN, IHI Facts or Fiction? Don t need to concern oneself with the nursing terminologies now that we have SNOMED CT (NANDA, NOC, NIC, PNDS, Omaha System, ICNP are all mapped in it can be used interchangeably) ICNP is the new internationally accepted nursing terminology and up in computerized systems throughout the world CCC is the new US government designated nursing terminology of choice Don t use a standardized terminology if you have to pay for it Facts or Fiction? It is inappropriate and undesirable to pay to use a terminology set HL7 is the only place to put our efforts nursing informatics resources, all informatics nurses should belong All we need to do is get nurses at the policy tables and they will represent nursing s informatics agenda
What Are the Facts? Contact Information for: Karen S. Martin, RN, MSN, FAAN Email: martinks@tconl.com Phone: 402 333 1962 Web: http://www.omahasystem.org Contact Information for: Sue Moorhead, RN, PhD sue moorhead@uiowa.edu Phone: 319 335 7051 E mail: classification center@uiowa.edu Web: http://www.nursing.uiowa.edu/cnc The Center for Nursing Classification & Clinical Effectiveness The University of Iowa College of Nursing 407 NB Iowa City, IA 52242, USA
Contact Information for: Kathy Lesh, RN BC, EdM, MS Email: klesh@mitre.org or kathy.lesh@gmail.com Phone: 703 983 1350 Web: http://www.nursingworld.org/npii/ SPIN