20 th Annual Anniversary Summer Institute in Nursing Informatics SINI Nursing Informatics: From First Use to Meaningful Use University of Maryland
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1 20 th Annual Anniversary Summer Institute in Nursing Informatics SINI Nursing Informatics: From First Use to Meaningful Use University of Maryland SON Baltimore, MA July 21-24, 2010
2 Terminologies & Standards Overtime Virginia K. Saba, EdD, RN, FAAN, FACMI President & CEO Sabacare Inc. Distinguished Scholar, Adjunct, Georgetown University, NHS 2
3 Objectives Describe Healthcare Terminologies & Standards Over Time that Impact Nursing Documentation in the EHR. Characteristics of a Standardized Nursing Terminology: Clinical Care Classification (CCC) System for Nursing Documentation in the E H R.
4 Describe Healthcare Terminologies & Standards Over Time that Impact Nursing Documentation in the EHR. 4
5 Terminologies & Standards Terminology: The set of terms representing a system of concepts (ISO 1087). Concept: A unit of thought constituted through abstraction on the basis of properties common to a set of objects (ISO 1087). Standard: Is a yardstick, rule, principle, established by law.
6 Early Nursing Terminologies 6 Cannons-Nightingale 14 Activities Henderson (1940s) 21 Nursing Problems Abdellah (1950s) 6 Self-Care Deficits Orem (1960s) 4/5/6 Steps Nursing Process Yura & Walsh; ANA (1970s)
7 Recent Nursing Terminologies 1976 NANDA -Nursing Diagnoses 1990 Nursing Minimum Data Set (NMDS) 1991 CCC System (HHCC) 1992 ANA Recognized 1 st 4 Nursing Terminologies of 12 total 1994 UMLS (NLM): Integrated 6 Nursing Terminologies 2000 SNOMED: Integrated 6 Nursing Terminologies 2007/8 CCC System: 1 st National Nursing Standard (HITSP)
8 CMS Medicare 2005 Regulations / Data Needs Reasonable Preventable Conditions Injuries From Patient Falls Pressure Ulcers Urinary-Tract Infections Vascular, Catheter, & Infections Three Never Events: Objects Left During Surgery Air Embolisms Blood Incompatibility 8
9 Current Nursing Practice Patients sicker & need complex care Patients - chronic Illnesses & live longer. Care based on intuition/trial & error/ not on measurements, evidence, or data. Nursing notes not quantifiable Nursing documentation not interoperable
10 Nursing Documentation What Coded Terminology? Admission Assessment Administer Medical Orders Plans of Care Nursing Orders Nursing Progress Notes Discharge Instructions/Summary
11 Nursing / HealthCare Challenge President Obama s Vision & Priority is establishing e-health Patient Records by
12 e-health Initiatives Prior 1991 Fragmented HIT Systems 1991 IOM CPR 2003 Call to Action 2004: HHS Strategy: ONC Formed 2005:ANSI-HITSP: Use Cases 2006: Executive Order-EHR by /8: 1 st Set of 55 National Standards 1 st National Nursing Standard (CCC System)
13 CCC System-Interface Terminology Free National Nursing Coded Terminology Standard Discrete Data Elements of Nursing Practice Atomic Level Concepts: Storage, Retrieval, Aggregation, Analysis & Re-Use Outcomes: Measurable for Meaningful Use Interface Terminology Links Nsg. DXs, to RXs, to OXs together & to Other Terminologies e.g ICD Interoperable - Map to Other Systems (via CCC or SNOMED)
14 SNOMED Reference Terminology (CT) Metathesaurus of UMLS Relational Terminology Free from NLM in USA &? In Europe 30 + Clinical Modules of over 100,000 terms: Clinical Findings, Procedures, Body Structure, & Specimens Integrated 6 Nursing Classifications e.g. CCC System
15 CCC Intervention/Actions CCC Diagnoses Excerpt of CCC SNOMED Mapping
16 Integrating the Healthcare Enterprise (IHE) Goal: To Develop Technical Interoperable Structures for HITSP Standards 2009: Patient Plan of Care (PPOC) Profile Model follows Nursing Process Uses CCC System Example 2010: Discharge Summary 2011: Admission Assessment
17
18 IHE: Coded PPOC Profile IHE Process Terminology Signs/ Symptoms: Rationale for: To Identify: Plan & Implement To Evaluate Review Signs/Symptoms Nursing Process Terminology Assessment Nursing Diagnoses Expected Outcomes Nsg Intervention/Actions Actual Outcomes Re-Assessment 18
19 IHE: Coded PPOC Profile Status Report From Nurse to Nurse Change of Shift From Unit to Unit In-Hospital Transfers From Hospital to Hospital Discharge Referrals 19
20 CCC Multidisciplinary Interface Terminology & Interoperable with Systems CCC Interface Terminology Interface Terminology ICD-9 Multidisciplinary Terminology CCC Interface Terminology SNOMED-CT Interface Terminology
21 American Recovery & Reinvestment Act of 2009 (ARRA) Pres. Obama- HITECH Act 2/17/ billion-19 billion/ IT& 2 billion ONC Dr. David Blumenthal-ONC Coordinator Health IT Policy Committee (C. Delaney) Framework: Meaningful Use Health IT Standards Committee: (J. Murphy) Standards/Implementation Specifications 2009: ARRA: Use 55 HITSP/HHS Standards 2010: Implement Meaningful Use: 3 Phases
22 How Will Nursing be Used For Meaningful Use? 2011: CPOE How to Document MD Orders? Checklist or Plan of Care 2013: Quality Indicators How to Document / Not Coded 2015: ehealth Record /Outcomes How to Document Clinical Outcomes Patient Plan of Care (PPOC):Interoperability
23 Characteristics of a Standardized Nursing Terminology: Clinical Care Classification (CCC) System for Nursing Documentation in the E H R. 23
24 Where Did CCC Originate? HCFA Funded Research Project GT University PI Dr. Virginia K. Saba Develop a Classification Method to Predict Resource Needs and Evaluate Outcomes Records from 8,967 Cases -646 Facilities 40,000 Problems/Nursing Diagnoses 70,000 Interventions/Services
25 What is CCC System (2.0)? Empirically Developed Two Interrelated Terminologies-Forms a Single System to Code & Document Nursing Care in EH R: CCC of Nursing Diagnosis (ICD for Nursing) CCC of Nursing Outcomes CCC of Nursing Interventions Actions (CPT for Nursing) Classified by 21 Care Components
26 CCC System Framework 4 Care Patterns 21 Care Component Classes 182 Diagnoses 549 Outcomes 198 Interventions 792 Actions
27 CCC Care Component Classes Classifies Nursing Diagnoses & Interventions 1. Activity 2. Bowel Elimination 3. Cardiac 4. Cognitive 5. Coping 6. Fluid Volume 7. Health Behavior 8. Life Cycle 9. Medication 10. Metabolic 11. Nutritional 12. Physical Regulation 13. Respiratory 14. Role Relationship 15. Safety 16. Self-Care 17. Self-Concept 18. Sensory 19. Skin Integrity 20. Tissue Perfusion 21. Urinary Elimination 27
28 Health / Care Patterns CCC System Framework Health Behaviors Psychological Functional Physiological Care Component Classes Medication Safety Health Behavior Cognitive Coping Role Relationship Self Concept Activity Fluid Volume Nutritional Self-Care Sensory Cardiac Respiratory Metabolic Physical Regulation Skin Integrity Tissue Perfusion Bowel Elimination Urinary Elimination Life Cycle 182 Nursing Diagnoses 546 Outcome Statements 182 X 3 modifiers 792 Care Interventions 198 X 4 Type Action modifiers
29 CCC of Nursing Diagnosis (2.0) Identifies Patient Problems: 182 Diagnoses 59 Major & 123 Subcategories Forms Basis for 549 Outcomes Expected & Actual Outcomes Nursing Diagnosis + 1 of 3 Modifiers 1) Improve, 2) Stabilize, 3) Deteriorate
30 Nursing Diagnosis Definition A clinical judgment about individual, family or community responses to actual and potential health problems / life processes Provides the basis for selection of nursing interventions to achieve patient outcomes for which the nurse is accountable Approved, NANDA 1992.
31 Examples: CCC of Nursing Diagnoses-Requiring Intervention Actions Activity Alteration [A01.0] Bowel Elimination Alteration [B03.0] Dying Process [E10.0] Urinary Elimination Alteration [T49.0]
32 Examples: CCC of Nursing Goal/Expected Outcomes Diagnosis: Activity Alteration [A01.0] Activity Alteration will Improve [A01.0.1] Activity Alteration will Stabilize [A01.0.2] Activity Alteration will Deteriorate [A01.0.3]
33 CCC of Nursing Inteventions (2.0) Documents Patient Care: 792 Nursing Intervention Actions 198 Interventions /4 Action Types Identifies Action Types via 4 Modifiers Assess / Monitor Perform / Care Teach / Instruct Manage / Refer
34 Nursing Intervention Definition Single nursing action designed to achieve an outcome for a nursing or medical diagnosis and for which the nurse is accountable
35 Examples: CCC of Nursing Intervention Action Types Core Intervention Concept: Mobility Therapy: A03.0 Intervention Action Types Assess Mobility Therapy: A Perform Mobility Therapy: A Teach Mobility Therapy: A03.0.3] Manage Mobility Therapy: A03.0.4]
36 Examples: CCC of Nursing Actual Outcomes Diagnosis: Activity Alteration [A01.0] Activity Alteration Improved [A01.0.1] Activity Alteration Stabilized [A01.0.2] Activity Alteration Deteriorated [A01.0.3]
37 CCC Coding Structure 5 Characters (ICD-10 Structure) 1 st : one alpha character 2 nd & 3 rd : two-digit Major category 4 th : one-digit Subcategory 5 th : Modifier Example: L26.2.2
38 CCC System Information Model: PPOC Signs & Symptoms Nursing Diagnoses Nursing Outcomes Evidence Expected Outcomes Actual Outcomes To Improve To Stabilize To Support/Deteriorate Nursing Interventions Action Types Assess Care Teach Manage Improved Stabilized Supported/Deteriorated Copyright : 02/06 Created by: DHL 02/06 Virginia Saba,Ed.D, RN,FAAN, FACME & Jean Arnold, Ed.D, RN, BC
39 CCC Coded Plan of Care RN DX Breathing Pattern Impairment Assessment (Signs & Symptoms): Shortness of breadth when walking more than 20 feet Rib Pain when Coughing Provider/MD Diagnosis: Pneumonia RN Diagnosis: Breathing Pattern Impairment: CCC = L26.2
40 CCC Coded Plan of Care RN DX Breathing Pattern Impairment Expected Outcome Breathing Pattern Impairment will get better - Improve: CCC = L Provider.MD Orders Oxygen Therapy : Continuous 10 Liters Medication for Pain prn Instruct breathing exercises
41 CCC Coded Plan of Care RN DX - Breathing Pattern Impairment Plan: Nursing Orders Interventions /Actions Perform Oxygen Therapy Care L Admin (Perform) Pain Scale Q Perform Medication Treatment for Pain H Teach Breathing Exercises L36.1.3
42 CCC Coded Plan of Care RN DX - Breathing Pattern Impairment Actual Outcome: Breathing Pattern Improved : L Outcomes No Shortness of Breath Oxygen Discontinued No pain with cough Evidence Measures: # of Times Oxygen Administered Total Meds Administered
43 Value of CCC Coded Terminology t Document Plan of Care Nursing Diagnoses Provides Rationale for Intervention Actions & Outcomes Enables Actual Outcomes to be Measured in Relation to Expected Outcomes. Nursing Interventions Provides Evidence- Based of Nursing Practice / Decision Support Nursing Intervention Actions (# & Time) can Provide Staff Workload, Resources, & Cost
44 SouthCoast Care Plan
45 Example: CCC System at SouthCoast Hospitals Group Built on a Commercial-off-the-Shelf Automated System (Meditech) CCC Plans of Care: Nursing & Ancillary Documentation Provides Structure to Use in E H R Links Nsg Dx with Interventions & Outcomes Quantifies Essence of Nursing Care Facilitates Retrieval of Data 45
46 Why Use National Nursing Coded Terminology Standard - CCC System Ensure Visibility & Viability of the Nursing Profession in EHR Develop PPOCs - Coded Interactive Standardized Nursing Terminology that Links DXs torxs & OXs Essence of Nursing Care Measure Outcomes to Demonstrate: Value of Nursing Care Advance Nursing Science
47 CCC Web Site Contact: ation.com
48 CCC
49 Clinical Care Classification (CCC) System (2.0) Summary
50 CCC System Facts No Licensing Fee (Permission) Open Architecture Interoperability with ANSI HL7 Atomic Level Concepts Tested & Applicable in all Healthcare Settings Integrated in SNOMED CT & UMLS
51 CCC Facts (cont d) Designed for computer-based systems (EHR, EPR, EMR, CPR) Conforms to Cimino Criteria for a Standardized Terminology Recognized by ANA Conforms to ISO RT Model for Nursing Developed empirically from research of live patient care data
52 CCC System Facts (cont d) Codes based on ICD-10 structure for information exchange promoting interoperability Coded Standardized Framework for electronic documentation, storage analysis & retrieval Electronically links Nursing Diagnosis to Interventions and Outcomes Designed for determining care costs
53 CCC System Translations Has been translated into Dutch Chinese Finnish Portuguese Spanish German Korean Slovania Turkish Additional translations in process
54 CCC System Applications North Karelia Central, Turku Health Center, Kupio & Orhon Hospitals, Finland & Finish Health System Research: UCSF-AIDS Inpatients with Pneumonia Columbia Univ.: PDA to Record Student Clinical Care George Mason University: Feeg Tested Educational Use EHR System Vendors, e.g., Siemens, Eclipsys, Epic etc. Hospital E H Rs: Rush, SouthCoast Hospital Group, HCA, Claxton-Hepburn, Vanderbilt Hospital, etc.
55 Cimino: Desiderata Content: Domain Completeness Concept Orientation: One atomic level concept (Unambiguous) Concept Permanence: One concept cannot be reused Unique Identifier: One unique code
56 Cimino: Desiderata con t Polyhierachy: Hierarchial Arrangement CCC RX=2 levels Formal Definition: One unique meaning. Reject Not elsewhere Classified: Catchall Other not used Multiple Granularity: Multipurpose
57 Cimino: Desiderata con t Compositionality: Ability to combine simple concepts into composite concepts (CCC RX two levels) Multiple Consistent View: Langauge Independence: Translated in other langauges Designed for Computer Processing: EHR Systems
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