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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

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

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
Overview
  • 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
What is PMRI?
  • 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
Purpose of PMRI
  • Reminder to providers
  • Communication among providers
  • Source of data for
    • payers
    • managers
    • researchers
problems with pmri
Problems with PMRI
  • Idiosyncratic recording by clinicians: data difficult to
    • retrieve
    • interpret
    • aggregate
    • analyze
  • Clinicians and others require different concept representations.
problems with pmri 2
Problems with PMRI (2)
  • 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
Status of Nursing Vocabularies
  • 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
Benefits of standard nursing terminology
  • 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
what can government do
What can government do?
  • Mandate reports on quality, effectiveness, and costs based on clinical nursing data.
  • Require clinically validated terminologies at appropriate levels of granularity.
what can government do 2
What can government do? (2)
  • Mandate terminologies that meet emerging criteria (ASTM).
  • Support research and conferences to develop and test terminologies in nursing and allied health.
comparability of prmi
Comparability of PRMI
  • 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
Patient Care Data Set
  • 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
patient care data set14
Patient Care Data Set
  • 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
22 Care Components(derived from HHCC)
  • Activity
  • Circulation
  • Cognition
  • Coping and Mental Health
  • Fluids and Electrolytes
  • Gastrointestinal Function
  • Health Knowledge and Behaviors
22 care components 2
22 Care Components (2)
  • Immunology
  • Medications and Blood Products
  • Metabolism
  • Nutrition
  • Physical Regulation
  • Pre-, Intra-, Post-Procedure
  • Respiration
22 care components 3
22 Care Components (3)
  • Role Relationships
  • Safety
  • Self Care
  • Self Concept
  • Sensation, Pain, and Comfort
  • Tissue Integrity
  • Tissue Perfusion
  • Urinary Elimination
slide18
AXES
  • Problems
  • Goals
  • Orders
elements on problems axis
Elements on Problems Axis
  • Subject
  • Object
  • Likelihood
  • Status
  • Degree
  • Duration
  • Value
elements on problems axis 2
Elements on Problems Axis (2)
  • Frequency
  • Body Site
  • Laterality
example problem statement
Example Problem Statement

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

elements on goals axis
Elements on Goals Axis
  • Subject
  • Object
  • Performance
  • Level of Performance
  • Equipment
  • Manifestations
  • Goal Evaluation Status
example goal statement
Example Goal Statement

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

elements on orders axis
Elements on Orders Axis
  • Subject
  • Object
  • Action
  • Indicators
  • Method
  • Risk Factors
example order set for activity restrictions
Example Order Set for “Activity Restrictions”
  • 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
Comparison of PCDS to HHCC and Omaha
  • All derived from patient records
  • HHCC & Omaha: home care; PCDS: acute care
  • PCDS uses components modified from HHCC
comparison to nanda and icnp
Comparison to NANDA and ICNP

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
Comparison to NIC
  • PCDS Orders compare in granularity to NIC Activities.
  • NIC developed by consensus process; PCDS derived from patient care documents
comparison to noc
Comparison to NOC
  • 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
How to make nursing vocabularies converge?
  • Nursing Vocabulary Summit Conference, Vanderbilt, June 99
  • All vocabulary authors
  • Language & standards experts
  • Federal agencies
  • Professional organizations
  • Health care agencies
  • Health informatics industry
deliverables
Deliverables
  • Recommendations for further development
  • Guidelines / desiderata
  • Papers for publication
  • Presentations
process
Process
  • Briefing book
  • Learning about language & standards
  • Setting goals
  • Small group work toward goals
  • Reporting and disseminating
financial support
Financial Support
  • National Library of Medicine
  • Div. Of Nursing, HRSA
  • AMIA Nursing Informatics WG
  • American Medical Association
  • 3M
  • CareCentric Solutions
  • Cerner Corporation
financial support 2
Financial Support (2)
  • IDX
  • Kaiser Permanente
  • Lexical Technology
  • McKessonHBOC
  • Oceania
  • SMS
  • SNOMED International
offer
Offer

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

thank you
Thank you.
  • For further information see
    • Full text of testimony
    • Profile of PCDS
  • Or contact
    • Judy.Ozbolt@mcmail.vanderbilt.edu
    • 615-936-1557