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Required Information for the Patient Record: Nursing and Allied Health Testimony to the NCVHS Terminology Hearings May 17-18, 1999 Judy G. Ozbolt, Ph.D., R.N., F.A.A.N., F.A.C.M.I., F.A.I.M.B.E. Professor of Nursing and Biomedical Informatics, Vanderbilt University Overview

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Required information for the patient record nursing and allied health l.jpg

Required Information for the Patient Record: Nursing and Allied Health

Testimony to the

NCVHS Terminology Hearings

May 17-18, 1999


Judy g ozbolt ph d r n f a a n f a c m i f a i m b e l.jpg

Judy G. Ozbolt, Ph.D., R.N., F.A.A.N., F.A.C.M.I., F.A.I.M.B.E.

Professor of Nursing and Biomedical Informatics,

Vanderbilt University


Overview l.jpg
Overview F.A.I.M.B.E.

  • Definitions and requirements

  • Issues for government action

  • Comparability of PMRI

  • The Patient Care Data Set

  • The Nursing Vocabulary Summit Conference, June 10-13, 1999


What is pmri l.jpg
What is PMRI? F.A.I.M.B.E.

  • All data recorded during care

  • by providers of all disciplines

  • Usually assessment, diagnoses, orders, documentation of care

  • Rarely goals and clinical outcomes (physiological, cognitive, affective, behavioral, functional)


Purpose of pmri l.jpg
Purpose of PMRI F.A.I.M.B.E.

  • Reminder to providers

  • Communication among providers

  • Source of data for

    • payers

    • managers

    • researchers


Problems with pmri l.jpg
Problems with PMRI F.A.I.M.B.E.

  • Idiosyncratic recording by clinicians: data difficult to

    • retrieve

    • interpret

    • aggregate

    • analyze

  • Clinicians and others require different concept representations.


Problems with pmri 2 l.jpg
Problems with PMRI (2) F.A.I.M.B.E.

  • NO standards for nursing data

  • NO retrievable data for services that consume 1/3 of operating budget of hospitals

  • Can’t study effectiveness and cost-effectiveness of those services


Status of nursing vocabularies l.jpg
Status of Nursing Vocabularies F.A.I.M.B.E.

  • 7 recognized by ANA lack comprehensiveness, granularity, atomic elements, combinatorial grammar

  • Diverse in purpose, scope, form, content, and development

  • No de facto standard

  • No unified language


Benefits of standard nursing terminology l.jpg
Benefits of standard nursing terminology F.A.I.M.B.E.

  • Building blocks for plans and pathways: project care requirements and staffing needs

  • Decision support via hyperlinks

  • Databases for quality, research

  • Sensitive measures of quality and effectiveness to guide purchasing and regulations


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What can government do? F.A.I.M.B.E.

  • Mandate reports on quality, effectiveness, and costs based on clinical nursing data.

  • Require clinically validated terminologies at appropriate levels of granularity.


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What can government do? (2) F.A.I.M.B.E.

  • Mandate terminologies that meet emerging criteria (ASTM).

  • Support research and conferences to develop and test terminologies in nursing and allied health.


Comparability of prmi l.jpg
Comparability of PRMI F.A.I.M.B.E.

  • Data currently NOT comparable

  • Comparable data critical to identify best value services--best balance of cost and outcomes

  • Comparable data necessary to reimburse, study, and improve patient care services


Patient care data set l.jpg
Patient Care Data Set F.A.I.M.B.E.

  • Version 4.0, 1998

    • Codes and pre-coordinated terms for Problems (363 terms), Goals (311 terms), Orders (1357 terms)

    • Outcomes defined as Goal Evaluation Status

  • Developed and tested at UVA, in collaboration with UHC


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Patient Care Data Set F.A.I.M.B.E.

  • Validated as comprehensive of most terms used in acute care

  • Undergoing revision:

    • Parsed into atomic-level elements

    • Combinatorial grammar

    • Values of elements (from practice)

    • Links among values: clinical knowledge


22 care components derived from hhcc l.jpg
22 Care Components F.A.I.M.B.E.(derived from HHCC)

  • Activity

  • Circulation

  • Cognition

  • Coping and Mental Health

  • Fluids and Electrolytes

  • Gastrointestinal Function

  • Health Knowledge and Behaviors


22 care components 2 l.jpg
22 Care Components (2) F.A.I.M.B.E.

  • Immunology

  • Medications and Blood Products

  • Metabolism

  • Nutrition

  • Physical Regulation

  • Pre-, Intra-, Post-Procedure

  • Respiration


22 care components 3 l.jpg
22 Care Components (3) F.A.I.M.B.E.

  • Role Relationships

  • Safety

  • Self Care

  • Self Concept

  • Sensation, Pain, and Comfort

  • Tissue Integrity

  • Tissue Perfusion

  • Urinary Elimination


Slide18 l.jpg
AXES F.A.I.M.B.E.

  • Problems

  • Goals

  • Orders


Elements on problems axis l.jpg
Elements on Problems Axis F.A.I.M.B.E.

  • Subject

  • Object

  • Likelihood

  • Status

  • Degree

  • Duration

  • Value


Elements on problems axis 2 l.jpg
Elements on Problems Axis (2) F.A.I.M.B.E.

  • Frequency

  • Body Site

  • Laterality


Example problem statement l.jpg
Example Problem Statement F.A.I.M.B.E.

Patient has confirmed, chronic, moderately impaired range of motion (60% of normal) of left shoulder.


Elements on goals axis l.jpg
Elements on Goals Axis F.A.I.M.B.E.

  • Subject

  • Object

  • Performance

  • Level of Performance

  • Equipment

  • Manifestations

  • Goal Evaluation Status


Example goal statement l.jpg
Example Goal Statement F.A.I.M.B.E.

Patient will achieve range of motion within acceptable range (80-90% of normal) by use of appropriate equipment.


Elements on orders axis l.jpg
Elements on Orders Axis F.A.I.M.B.E.

  • Subject

  • Object

  • Action

  • Indicators

  • Method

  • Risk Factors


Example order set for activity restrictions l.jpg
Example Order Set for “Activity Restrictions” F.A.I.M.B.E.

  • Assess patient’s patterns and levels of activity.

  • Assess patient’s understanding of activity restrictions and rationale.

  • Encourage patient’s asking persons to provide assistance.


Comparison of pcds to hhcc and omaha l.jpg
Comparison of PCDS to HHCC and Omaha F.A.I.M.B.E.

  • All derived from patient records

  • HHCC & Omaha: home care; PCDS: acute care

  • PCDS uses components modified from HHCC


Comparison to nanda and icnp l.jpg
Comparison to NANDA and ICNP F.A.I.M.B.E.

PCDS NANDA ICNP

Subject Unit of Care

Object Diagnostic Concept Focus of Care

Status Modifier Judgment

Likelihood Potentiality Likelihood

Duration Acuity/Chronicity Chronicity

Degree Degree

Value Value

Frequency Frequency

Laterality Laterality

Body Site Body Site


Comparison to nic l.jpg
Comparison to NIC F.A.I.M.B.E.

  • PCDS Orders compare in granularity to NIC Activities.

  • NIC developed by consensus process; PCDS derived from patient care documents


Comparison to noc l.jpg
Comparison to NOC F.A.I.M.B.E.

  • NOC provides valid and reliable measures of conditions or behaviors as outcomes.

  • PCDS defines outcomes as Goal Evaluation Status; useful for effectiveness studies, consistent with HL7.


How to make nursing vocabularies converge l.jpg
How to make nursing vocabularies converge? F.A.I.M.B.E.

  • Nursing Vocabulary Summit Conference, Vanderbilt, June 99

  • All vocabulary authors

  • Language & standards experts

  • Federal agencies

  • Professional organizations

  • Health care agencies

  • Health informatics industry


Deliverables l.jpg
Deliverables F.A.I.M.B.E.

  • Recommendations for further development

  • Guidelines / desiderata

  • Papers for publication

  • Presentations


Process l.jpg
Process F.A.I.M.B.E.

  • Briefing book

  • Learning about language & standards

  • Setting goals

  • Small group work toward goals

  • Reporting and disseminating


Financial support l.jpg
Financial Support F.A.I.M.B.E.

  • National Library of Medicine

  • Div. Of Nursing, HRSA

  • AMIA Nursing Informatics WG

  • American Medical Association

  • 3M

  • CareCentric Solutions

  • Cerner Corporation


Financial support 2 l.jpg
Financial Support (2) F.A.I.M.B.E.

  • IDX

  • Kaiser Permanente

  • Lexical Technology

  • McKessonHBOC

  • Oceania

  • SMS

  • SNOMED International


Offer l.jpg
Offer F.A.I.M.B.E.

Will provide formal report of the conference to the committee by end of summer


Thank you l.jpg
Thank you. F.A.I.M.B.E.

  • For further information see

    • Full text of testimony

    • Profile of PCDS

  • Or contact

    • [email protected]

    • 615-936-1557


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