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Russell McGuire, MSN, RN. Director of Clinical Services, DHS. Appalachian Regional ... Benchmark - Established Norm of Services Treatments/ Supplies ...
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Slide 1: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.
Slide 2: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
Slide 3: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 1) Appalachian Regional Healthcare’s Division of Home Services was created in 1983, starting from 2 agencies in eastern Kentucky to a service provider of 23 home health agencies and branches. The Division of Home Services provides consultation for the administration of the University of Kentucky’s Home Health Agency. The Division is also responsible for the administration of 25 DME stores. 2) The Division of Home Services has experienced successful growth starting with 32,000 visits in 1969 to over 500,000 visits for the fiscal year 95-96. 3) Home health services are provided in the Appalachian Regions of eastern Kentucky, southern West Virginia, western Virginia, and northern Tennessee. 4) These services include skilled nursing, skilled therapies, and medical social services, infusion therapy, and we are currently beginning specialty services in wound care management, psychiatric nursing, cardiovascular nursing and geriatric nursing.1) Appalachian Regional Healthcare’s Division of Home Services was created in 1983, starting from 2 agencies in eastern Kentucky to a service provider of 23 home health agencies and branches. The Division of Home Services provides consultation for the administration of the University of Kentucky’s Home Health Agency. The Division is also responsible for the administration of 25 DME stores. 2) The Division of Home Services has experienced successful growth starting with 32,000 visits in 1969 to over 500,000 visits for the fiscal year 95-96. 3) Home health services are provided in the Appalachian Regions of eastern Kentucky, southern West Virginia, western Virginia, and northern Tennessee. 4) These services include skilled nursing, skilled therapies, and medical social services, infusion therapy, and we are currently beginning specialty services in wound care management, psychiatric nursing, cardiovascular nursing and geriatric nursing.
Slide 4:Nursing Informatics
Slide 5: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).
Slide 6: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.
Slide 7:Conceptual Framework
Data Information Knowledge Nursing Process Information and Communication Technology Atomic level Synthesis (raw facts) (interpreted facts) (synthesized information)
Slide 8:Nursing Classification Systems
Slide 9: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)
Slide 10: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.
Slide 11: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 NLN’s Council for Nursing Informatics.
Slide 12: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: ANA’s Social Policy Statement - “Nursing is the diagnosis and treatment of human responses to actual or potential health problems”.
Slide 13: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.
Slide 14: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.
Slide 15: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.
Slide 16: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.
Slide 17: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.
Slide 18: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.
Users Data/Information Scope 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. World health officials General health status and Worldwide Policy makers, Researchers health-related needs Data Lawmakers of individual nations. 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 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 ABSTRACTED, SUMMARIZED, AGGREGATED ABSTRACTED, SUMMARIZED, AGGREGATED 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. DataSlide 20: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”.
Slide 21: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
Slide 22: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.
Slide 23: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.
Slide 24: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.
Slide 25: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.
NANDA, NIC, NOC, Impaired ? Are you ……Slide 27:Integration Into Nursing Practice
Slide 28: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.
Slide 29: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).
Slide 30: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.
Slide 31: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.
Slide 32: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.
Slide 33:ARH Experience With Nursing Classification Systems: NIC
NIC - nursing intervention project (Iowa project. Features. 433 documented, researched nursing interventions.
Slide 34: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.
Slide 35: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
Slide 36: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.
Slide 37:Extended Health Enterprise Model
Population Insurers Employers Regulatory Agencies Network Managed Care
Slide 38:Emerging Health Network Clinical 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.
Slide 39:Emerging Health Network Financial 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.
Patient Private Insurance Home Medical Equipment Provider Home I.V. Provider Pharmacy Medicare Medicaid Home Health Provider Skilled Nursing Non-Skilled Nursing Rehab TherapiesSlide 40:Traditional Homecare Model
Home Health Home I.V. Provider HMESlide 41:Today’s Homecare Model
Skilled Nursing Non-Skilled Nursing Pharmacy HME Rehab Therapies Self-Insured HMOs PPOs Medicare Medicaid Private Insurance Population PPS
Slide 42: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.
Slide 43: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.
Slide 44:Impact On Homecare Organizations New Information System
Clinical outcome data tracking. Practice guidelines formation and tracking. Customer satisfaction tools. Provider profiling. Provider performance.
Slide 45:KEY TO SUCCESS
Clinical excellence
Slide 46:Care Design
Problems/ Outcomes The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics.
Problems/ Outcomes Interventions/ Activities Care Design The Care Design/ Pathway Should Represent a Benchmark of Care Which Can Be Adapted to Specific Practices or Demographics. Problems/ Outcomes Interventions/ Activities Diagnosis ICD-9 Care Design 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 Design 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. Diagnosis ICD-9 Problems/ Outcomes Interventions/ Activities Level of Severity / Disease Care Design Diagnosis ICD-9Slide 51:Care Design Benchmark
Purpose: To Establish a Standard of Care As It Relates to a Specific Diagnosis, Level of Severity and Treatment.
Slide 52: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.
Actual Prescribed Benchmark Ideal Ultimate Goal
Slide 53: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.
Slide 54: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
Slide 55: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.
Slide 56:Pathways Homecare Technical Requirements
POC support Store and forward Laptops Connectivity Dial-up via a modem Hardware/operating system/RDBMS Sequeal server
