CIN: Computers, Informatics, Nursing
& Vol. 29, No. 1, 52–58 & Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
F E A T U R E
A R T I C L E
The Omaha System and
Meaningful Use
Applications for Practice, Education,
and Research
KAREN S. MARTIN, MSN, RN, FAAN
KAREN A. MONSEN, PhD, RN
KATHRYN H. BOWLES, PhD, RN, FAAN
‘‘Meaningful use’’ quickly became the most important
new term in informatics language after it was included
in the American Recovery and Reinvestment Act of
2009, Public Law 111-5. That law includes $19.5
billion for health information technology. It authorizes
the Centers for Medicare & Medicaid Services to provide reimbursement incentives for eligible professionals
and hospitals who become ‘‘meaningful users’’ of certified electronic health record (EHR) technology in three
stages (2011, 2013, 2015). Medicare reimbursement focuses on physicians, while Medicaid reimbursement also
includes dentists, certified nurse-midwives, nurse practitioners, and physician assistants.1
Meaningful use suggests that better healthcare does
not come solely from the adoption of technology itself,
but through interoperability or the exchange and use of
health information to best inform clinical decisions at
the point of care. Meaningful use incorporates complex
processes and workflow involving nurses and healthcare
practitioners; all providers should be considering how
they can be involved, regardless of their work site. The
Markle Foundation2 proposed that patient-centered,
meaningful use of health information technology demonstrates that the provider makes use of, and the patient
has access to, clinically relevant electronic information
about the patient to improve patient outcomes and
health status, improve the delivery of care, and control
the growth of costs. To achieve meaningful use, quality
measures must be converted to EHR metrics. In October
2009, David Blumenthal, national coordinator for Health
Information Technology, US Department of Health and
52
Meaningful use has become ubiquitous in the
vocabulary of health information technology. It
suggests that better healthcare does not result
from the adoption of technology and electronic
health records, but by increasing interoperability
and informing clinical decisions at the point of
care. Although the initial application of meaningful
use was limited to eligible professionals and
hospitals, it incorporates complex processes
and workflow that involve all nurses, other healthcare practitioners, and settings. The healthcare
community will become more integrated, and
interdisciplinary practitioners will provide enhanced patient-centered care if electronic health
records adopt the priorities of meaningful use.
Standardized terminologies are a necessary
component of such electronic health records.
The Omaha System is an exemplar of a standardized terminology that enables meaningful use
of clinical data to support and improve patientcentered clinical practice, education, and research. It is user-friendly, generates data that
can be shared with patients and their families, and
enables healthcare providers to analyze and
exchange patient-centered coded data. Use of
the Omaha System is increasing steadily in diverse practice, education, and research settings
nationally and internationally.
KEY WORDS
health information technology & meaningful use &
nursing & Omaha System & standardized terminology
Human Services, said, ‘‘The key to meaningful use is to
know how to measure for performance and to be able
to give feedback to providers.’’3(p1)
Meaningful use is based on a matrix of priorities that
flows from National Quality Forum work published
during 2008. The cornerstones of the matrix are (1)
Author Affiliations: Martin Associates, Omaha, NE (Ms Martin); University of Minnesota School of Nursing, Minneapolis, MN (Dr Monsen);
and University of Pennsylvania School of Nursing, NewCourtland
Center for Transitions and Health, Philadelphia, PA (Dr Bowles).
Corresponding author: Karen S. Martin, MSN, RN, FAAN, Martin
Associates, 2115 S 130th St, Omaha, NE 68144 (martinks@tconl.com).
DOI: 10.1097/NCN.0b013e3181f9ddc6
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improve quality, safety, efficiency, and reduce health disparities; (2) engage patients and families; (3) improve care
coordination; (4) improve population and public health;
and (5) ensure privacy and security protections.1 The
matrix includes detailed goals, objectives, and measures
to operationalize the cornerstones.
Numerous federal agencies, standards groups, and
membership organizations are actively involved in developing and responding to aspects of meaningful use. On
December 30, 2009, the Office of the National Coordinator issued the Interim Final Rule and Notice of Proposed Rulemaking, a lengthy document that addresses
the definition of meaningful use, standards, certification,
and the relationship of EHRs to Medicare and Medicaid.
Many additional rules and regulations will be issued. The
Certification Commission for Health Information Technology is currently authorized to test and certify clinical
information systems. Healthcare Information Technology
Standards Panel (HITSP), a public-private partnership
organization, has been harmonizing standards since 2006.
The National Quality Forum will continue to endorse
quality measures and work in partnership with the Agency
for Healthcare Research and Quality to develop a data
model for quality measurement.1
STANDARDIZED TERMINOLOGIES
The Alliance of Nursing Informatics (ANI) is a collaborative of 25 organizations that speaks as a unified
voice for nurses employed in practice, education, and
industry. In October 2009, ANI published a document
stating that ‘‘‘meaningful use’ of EHR systems should
strive for nothing less than an integrated healthcare community that is patient centered and promotes usable,
efficient, and seamless information flow.’’4(p65) The ANI
indicated that nurses are instrumental in coordinating
care across the continuum and connecting acute, ambulatory, long-term, community, home care, and public
health–based settings. The ANI stated that the use of
standardized nursing and other health terminologies ‘‘is
necessary and a prerequisite for decision support, discovery of disparities, outcomes reporting, improving performance, maintaining accurate lists of problems and
medications, and the general use and reuse of information
needed for quality, safety, and efficiency.’’4(p66)
Currently, the American Nurses Association (ANA)
recognizes 12 reference and interface terminologies.
SNOMED CT is an example of a reference terminology;
it consists of 310 000 active concepts organized into hierarchies, descriptions, relationships, and attributes that are
not visible to the practitioner. The seven interface terminologies recognized by ANA are Clinical Care Classification,
International Classification of Nursing Practice, NANDA
International, Nursing Interventions Classification, Nurs-
ing Outcomes Classification, Omaha System, and Perioperative Nursing Data Set.5,6
Interface or point-of-care standardized terminologies
are an important component of EHRs that enable capture
and representation of assessment, service, and outcome
data. Point-of-care terminologies and standardized care
plans or pathways are keys to advancing the federal mandate described in this article because they enable meaningful translation of care concepts to data. Nurses and
other healthcare practitioners use such terminologies to
describe, document, and quantify their daily practice in a
consistent manner. When practitioners use point-of-care
terminologies in an EHR accurately and consistently, they
generate a quality database that reflects the needs of
their patient population. Such data can be used to monitor quality of care, client health outcomes, and population health trends. In addition, clinical data from various
groups can be mapped to the reference terminologies.
THE OMAHA SYSTEM
The Omaha System is one of the point-of-care terminologies recognized by ANA and referred to in the ANI
document. It includes characteristics described for
meaningful use in that it is user-friendly, generates data
that can be shared with patients and their families, and
enables healthcare providers to analyze and exchange
patient-centered coded data. The Omaha System is congruent with standards mandated by the Office of the
National Coordinator, integrated into SNOMED CT and
Logical Observation Identifiers, Names, and Codes
(LOINC), registered by Health Level Seven (HL7), and
listed in HITSP Use Cases.7
The Omaha System originated at the Visiting Nurse
Association of Omaha (Nebraska) as a collaborative
effort between interdisciplinary practitioners and researchers. Four research studies conducted between
1975 and 1993 were federally funded. DeLanne Simmons,
chief executive officer, envisioned a computerized management information system that incorporated an integrated, valid, and reliable clinical information system
focused on patients who received services, not the practitioners who provided the services.7,8
The Omaha System exists in the public domain (open
source, no fee) and enhances practice, documentation,
and information management. It was designed to be
relatively simple, hierarchical, multidimensional, and
computer-compatible and used by interdisciplinary
practitioners to document and communicate information about patient care from admission to discharge. It
is intended for use across the continuum of care. It is
based on a conceptual model depicted in Figure 1 that
reflects the pivotal position of the individual, family,
and community; the partnership with practitioners; and
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53
scribe health-related problems, services, and outcomes.
These data can be used for meaningful use applications
such as exchange of patient and population information,
healthcare quality evaluation, and health services research.
Adoption of the Omaha System in practice, education,
and research has increased steadily since 1990, in part due
to its incorporation as the point-of- care terminology in
clinical software systems. Almost 300 articles, chapters,
and books written by national and international authors
are listed on the Web site, a reflection of its widespread
adoption.
MEANINGFUL USE OF THE OMAHA SYSTEM
Practice
FIGURE 1. Omaha System model of the problem-solving process.
Used with permission from Health Connections Press.8
the value of the problem-solving process.7,8 That model
reflects the meaningful use matrix of priorities.
The Omaha System consists of three relational, valid,
and reliable components designed to be fully integrated:
Problem Classification Scheme (patient-centered
assessment that engages the patients and their
families)
Intervention Scheme (plans, pathways, service
delivery to improve safety, quality, and effectiveness)
Problem Rating Scale for Outcomes (evaluation that
provides usable information for quality improvement)
The Problem Classification Scheme is a hierarchy that
includes domains; patient-, family-, and communitycentered problems; modifiers; and signs/symptoms. The
Intervention Scheme is a hierarchy of interventions that
includes categories, targets, and patient-specific information. The Problem Rating Scale for Outcomes consists of
knowledge, behavior, and symptom status concepts and
Likert-type rating scales. A detailed description of the
purpose, terms, definitions, codes, automation, and users
is available on the Omaha System Web site and book.7,8
Promoting the appropriate use of health information
technology is essential. During a 2009 Institute of Medicine workshop9 that addressed cost, quality, safety, outcomes, and innovation, health information technology
was the most commonly mentioned priority. Implementing a point-of-care terminology such as the Omaha System to structure clinical documentation is also a priority
for practice, education, and research. Use of the Omaha
System generates detailed standardized data that de54
Rapid advances in informatics and implementation of
EHRs have advanced the meaningful use of patient data.
Such EHRs provide a mechanism for disseminating
agency standards of care and generating clinical data.
Large practice-generated Omaha System data sets are
available for program evaluation and research. Healthcare leaders are using the Omaha System as a tool to
address the meaningful use goals: monitor and enhance
care quality, efficiency, and value; engage patients and
families; improve care coordination; and promote population health.9 For example, Minnesota public health
agencies have used Omaha System data to inform and
communicate clinical decisions at the point of care. In
particular, Washington County Minnesota Public Health
and Environment administrators, managers, nurses, and
other public health professionals worked together to establish a comprehensive, agency-wide outcomes management system based on the Omaha System.10,11
Diverse stakeholders from clinical settings, education,
research, and informatics have formed Omaha System
users groups to advance practice and meaningful use.
Groups in Minnesota and Washington are especially
active. In Minnesota, collaborative Omaha System data
quality and practice enhancement efforts began in 2001
and continue to expand to diverse agencies and programs. Four public health nursing agencies identified the
needs of home-visiting patients across county public
health agencies and demonstrated outcomes of services.
Behavioral, psychosocial, environmental, and physiological problems were similarly identified and addressed
in all agencies. Statistically significant improvement in
patient health problems occurred consistently across
agencies. Problems involving antepartum/postpartum
and family planning showed the greatest improvement;
the problems neglect and substance use showed the least
improvement. Based on these findings, the agencies
prioritized strategies for enhancing home-visiting interventions.12,13 The Minnesota Department of Health
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worked together with the Minnesota Omaha System
Users Group to gather data to evaluate a statewide homevisiting program.
In one Minnesota county, the Omaha System was used
to engage seniors in health promotion activities and
develop and evaluate community-level interventions addressing chronic health problems at senior high-rise
clinics. At senior blood pressure clinics, the standardized
protocol assessed four problems: circulation, medication
regimen, communication with community resources, and
mental health, plus a monthly teaching topic (eg, blood
pressure self-care). Seniors responded positively to the
health promotion clinics and actively engaged in monitoring their personal health. Analysis of data from senior
clinics showed that the most common problems were pain
and neuromusculoskeletal function. Public health nurses
used these findings to tailor the program interventions
and to improve care coordination and communication
about their program with local physicians.14
Similarly, efforts are under way to improve population
health using the Omaha System. Maine Centers for Disease Control used the Omaha System to create practice
standards for tuberculosis direct observed therapy, generate outcomes data, and report community-level outcomes to administrators and decision makers.15 In
Minnesota, a work group composed of local and state
public health agency personnel, asthma experts, nursing
researchers, and graduate students developed and tested
best practices pathways for asthma care at the individual
and community levels. These pathways are available
online for incorporation into any documentation system.
Public health and home care agencies in Minnesota and
Washington developed more than 130 standard pathways
that are available on the Minnesota Omaha System Users
Group Web site. The pathways are related to topics, such
as disease investigation, perinatal hepatitis B, refugee
health, public health nuisance, and elderly case management services, and to programs, such at the Nurse Family
Partnership and the Minnesota Family Home Visiting
Program. Washington agencies created shared homevisiting ‘‘core’’ pathways for use throughout the state
that address nine priority problems: pregnancy, postpartum, caretaking/parenting, income, mental health, abuse,
neglect, healthcare supervision, and substance use.14 Using
the Omaha System facilitated needs assessment, program
evaluation, and outcomes management processes for
these agencies and will continue to play an integral
role in guiding practice, increasing the value of services,
and thus improving patient and population outcomes.
Education
Informatics is revolutionizing nursing education in the
United States and globally; it affects all educators,
students, and aspects of curricula.16 Informatics is now
listed as one of the six competencies that graduates
must have to function effectively; the other competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement,
and safety.17 These competencies parallel the meaningful use matrix of priorities and the Omaha System.
Educators have been involved with the Omaha System
in a variety of ways. Some participated in the federally
funded developmental research conducted between 1975
and 1993. During the 1980s, faculty members began
introducing students to the Omaha System, primarily in
the community health course. Gilbey18 and her New
Brunswick, Canada, colleagues introduced the Omaha
System to increase students’ assessment skills.7,8 The
focus was on professional practice, quality care, decisionmaking skills, standardized documentation, and communication. Since then, use expanded to include many
nursing programs in the United States and some schools
internationally and includes diploma, associate degree,
baccalaureate, master’s, and doctoral programs. As healthcare professionals increase their collaborative use of clinical information systems, nursing educators are introducing
colleagues and students from other disciplines to the
Omaha System. Currently, faculty include the concepts
of meaningful use by emphasizing a problem-solving approach to practice, partnerships with patients, benefits
of efficient and effective documentation, an outcomes
orientation, and the value of using standardized health
information to inform clinical decisions at the point of
care.19
Increasingly, educators in the United States and globally embrace the Omaha System, EHRs, and the Internet
as essential components of curricula. The Omaha System
has been introduced to promote clinical reasoning, structured documentation, and research globally; educators
and students in Australia, Hong Kong, Iceland, Japan,
Korea, Turkey, New Zealand, Taiwan, the Netherlands,
and United Kingdom have published articles, chapters, and
books about their experiences. Educators recognize the
value in offering students hands-on informatics experiences in learning laboratories and clinical sites. More
than 50 schools in the United States and New Zealand
used FITNE’s Nightingale Tracker, in addition to San
Jose State University School of Nursing; schools are now
developing or purchasing more sophisticated Omaha System software.7,8
The University of Wisconsin–Milwaukee College of
Nursing established its first primary care nurse-managed
center in 1986. Although the primary goal was to provide
high-quality services for individuals and families who had
serious health-related problems, the secondary goal was
to establish a repository that faculty and students could
use to integrate clinical, financial, and statistical data.
Educators selected the Omaha System to standardize
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55
practice, documentation, and information management
and now have a 24-year data repository to analyze.
Approximately 20 University of Wisconsin–Milwaukee
educators, doctoral students, and master’s students have
conducted research based on the Omaha System. In
addition to nursing students, medical, social work, and
health career students are introduced to the Omaha
System during clinical experiences at the centers.7,8
San Jose State University School of Nursing, San
Jose, CA, is an exceptional Omaha System educational
site that exemplifies concepts of meaningful use. Early
in the 1990s, faculty leaders recognized that it was time
to embrace new practice models such as nurse-managed
centers, the Omaha System, and informatics. They
decided to integrate concepts in their curriculum and
implement the Omaha System at their centers.
Collaboration is one of the reasons that the San Jose
State University–Omaha System action plan has been
successful. Educators purchased books, scheduled their
first consultation and workshop in 1994, and published
their first Omaha System–related article in 1998.20 To
date, faculty and students published more than 15 related articles and chapters, presented numerous posters
and speeches, conducted 10 studies, shared case studies
on the Omaha System Web site, and will be the host
school for the 2011 Omaha System International Conference.21,22 San Jose State University–Omaha System
obtained grants to buy FITNE’s Nightingale Tracker in
1998, the first Omaha System–based point-of-care
technology developed explicitly for student use, and
was one of the seven FITNE Centers of Excellence. The
school purchased a more sophisticated Web-based clinical information system in 2008. A faculty member was
one of the leaders who incorporated the Omaha System
into the baccalaureate curriculum essentials for their
national psychiatric-mental health specialty in 2008.23
Educators and students have received public media coverage on campus, locally, at the state level, and nationally. They encouraged area practice sites to consider
using the Omaha System and provided ongoing support as those sites began purchasing software. Nursing
faculty developed partnerships with communication disorders, speech and language pathology, and chiropractor
colleagues to introduce their students to the Omaha
System.
Research
A substantial body of research exists that demonstrates
the meaningful use of the Omaha System. Studies span
the care of the low-birth-weight infants, perinatal and
postpartum women, chronically ill elders, and patients at
the end of life. Settings include acute care, home care,
primary care, nurse-managed centers, public health,
56
school nursing, and the community. The Omaha System
offers a powerful strategy to document the details of a
clinical research intervention and describe what happened, when, where, how, and to whom. Using the
Omaha System to document care enables researchers to
examine the relationship between patient complexity,
nursing interventions, and patient outcomes.
The Transitional Care Model created and tested by an
interdisciplinary team of researchers led by Dr Mary
Naylor at the University of Pennsylvania School of
Nursing uses the Omaha System to document the care
provided by advanced practice nurses as they implement
the Transitional Care Model.24 The Omaha System is the
core component of the clinical information system that
captures the numbers, types (hospital, home, and
physician office), timing, length, and the focus of each
visit. Advanced practice nurses use Omaha System patient problems and corresponding interventions to document the care they provide. In the clinical information
system, the meaningful use of the Omaha System supports the transfer of information from hospital to home,
skilled nursing facility, or nursing home, therefore playing a major role in continuity of care and communication of the plan of care from one setting to another. In
addition, the rating of the patients’ knowledge, behavior,
and status of symptoms related to each Omaha System
problem gives practitioners a clear, objective measure of
the baseline condition. Rating these concepts again at
intervals or at discharge enables comparisons of progress
or decline useful for quality monitoring and evaluating
the effectiveness of nursing interventions and progress
toward patient goals.
To date, the University of Pennsylvania teams have
used the Omaha System and demonstrated its usefulness
in acute care and home care and in supporting continuity
of care across settings through multiple studies with
nearly 1000 patients. Two recently completed studies
used the Omaha System to document care of cognitively
impaired and psychiatric patients, demonstrating its
usefulness with challenging populations.19,25
An Omaha System state-of-the-science research review
was published in 2005; the review noted that more than
40 unique studies were conducted between 1982 and
2003.8 Studies with components of meaningful use were
categorized as those that describe patient problems,
clinical practice, patient outcomes, and healthcare resource utilization. Additional studies noted in the chapter advanced the science of nursing classification and use
of the Omaha System in education.
A MEDLINE search on the keyword Omaha System
and limited to the years 2005–2010 returned many
additional studies since the last published review. Many
studies are related to the cornerstones of meaningful
use. These include studies that use Omaha System data
to describe clinical care and patient outcomes26 and
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others that extend the science of classification or terminology development.27 Additional examples are studies
that involve effectiveness research and data mining,28,29
quality measurement,22 and predict patient outcomes.30
Students continue to develop new programs of research
with multiple dissertations completed and under way
nationally and internationally. Furthermore, educators
at a variety of universities worldwide are currently conducting Omaha System studies.
Several recently completed studies clearly demonstrate
that the Omaha System can generate data congruent
with meaningful use. A data mining study29 provides
an example of the increasing rigor of Omaha System
research. Study findings revealed clusters of patients who
differed significantly in demographics, services, baseline
and final scores on the Problem Rating Scale for Outcomes, Omaha System problems, and signs and symptoms. This type of analysis can elucidate the resources
needed for various patient clusters and patterns of
interventions provided. Such analysis is valuable when
agencies examine their staffing patterns in relation to the
number of staff and the skill mix needed to care for their
patients.
Westra et al30 focused on the use of secondary data to
predict outcomes for older adults receiving home care
services. Their study compared outcome data obtained
by using the Omaha System and the Centers for
Medicare & Medicaid Services’ OASIS tool. Agency
staff abstracted data from the EHRs of 133 patients
and compared improvement in pain between the
Omaha System problem, pain, and the OASIS pain
outcome scores. Based on chart reviews, nurse managers concluded that the Omaha System data were a more
accurate reflection of patients’ pain status than the
OASIS data. In-service education sessions were conducted with staff to share the findings and develop
consistent guidelines for documentation of OASIS,
followed by monthly monitoring. A comparison of the
Centers for Medicare & Medicaid Services outcome
reports demonstrated improved documentation of pain
management from 45% in the first year to 64.5% in the
second year. Findings from this study support the value
of the Omaha System for conducting quality improvement studies.
Barkauskas et al27 demonstrated an opportunity to
increase meaningful use within nurse-managed centers.
Only 31% of the 60 centers that responded to a national
survey were using a standardized language. Of these, the
majority (70%) were using the Omaha System. This
reveals substantial opportunities to increase the use of
the Omaha System within the remaining 69% of nursemanaged centers and therefore gain the meaningful use
benefits afforded by a standardized language to understand the unique contribution of nursing to quality
patient care.
SUMMARY
The Omaha System is an exemplar of a standardized
terminology that enables meaningful use of clinical data
to support and improve patient-centered clinical practice,
education, and research. This article provides national
and international examples across a variety of healthcare
settings and patient populations. The examples illustrate
the federal initiative to invest in information technology
and promote meaningful use: a patient-centered, interdisciplinary approach to care; improved workflow and
communication; and use and reuse of information. The
examples are congruent with the cornerstones of the
National Quality Forum matrix by enhancing clinical
decisions at the point of care, increasing the quality of
care, promoting interoperability, and decreasing costs.
For 4 decades, nurses have provided visionary leadership in the creation and use of point-of-care terminologies
such as the Omaha System. Today, nurses in practice,
education, and research settings are leaders as they
develop tools and methods to support meaningful use of
the structured data generated by these terminologies.
Nurses are needed as active participants in advancing the
robust science of nursing informatics within organizations and practice communities, locally, nationally, and
globally. National and international developments have
the potential to increase interoperability and improve the
quality of care.
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