Practice-Based Informatics Research
2012 State of the Science Congress on Nursing
Research, “Discovery through Innovation”
Bonnie L. Westra, PhD, RN, FAAN, FACMI
Associate Professor, University of Minnesota, School
of Nursing; Co-Director Center for Nursing Informatics
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Objectives
1. Describe the Omaha System.
2. Summarize state of the science using the
Omaha System research.
3. Describe next steps for advancing nursing
science with Omaha System data.
Omaha System
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Comprehensive, user friendly terminology, describes a
holistic view of health for individuals, families, and
communities
Originated in 1975, supported by multiple federal grants,
updated in 2005
Three components
• Problem Classification Scheme
• Intervention Scheme
• Problem Rating Scales for Outcomes
Includes terms/ concepts, definitions, and codes
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http://omahasystemmn.org/documents/2009_Omaha_System_concept_map.pdf © K Monsen 2009
Environmental
Psychosocial
Income
Sanitation
Residence
Neighborhood/
workplace
safety
Communication
with community
resources
Social contact
Role change
Interpersonal
relationship
Spirituality
Grief
Mental health
Sexuality
Caretaking/
parenting
Neglect
Abuse
Growth and
development
Physiological
Hearing
Vision
Speech and language
Oral health
Cognition
Pain
Consciousness
Skin
Neuro-musculo-skeletal
function
Respiration
Circulation
Digestion-hydration
Bowel function
Urinary function
Reproductive function
Pregnancy
Postpartum
Communicable/ infectious
condition
Health Related
Behaviors
Nutrition
Sleep and rest
patterns
Physical activity
Personal care
Substance use
Family planning
Health care
supervision
Medication regimen
Example of Omaha System
Caretaking/parenting – providing support, nurturance, stimulation
and physical care for dependent child or adult
□ difficulty providing physical care/safety
□ difficulty providing emotional nurturance
□ difficulty providing cognitive learning experiences and activities
□ difficulty providing preventive and therapeutic health care
□ expectations incongruent with stage of growth and development
□ dissatisfaction/difficulty with responsibilities
□ difficulty interpreting or responding to verbal/nonverbal
communication
□ neglectful
□ abusive
□ other
Intervention Examples –
Caretaking/ Parenting
Category
Target
Client Specific Data
CM
environment
Transitions in housing and levels of care
CM
finances
resources available to assist with financial
needs associated with caregiving
S
coping skills
S
TGC
safety
caretaking/
parenting skills
TGC
continuity of care
coordination among providers and resources
TGC
coping skills
realistic expectations
manages challenges and changes
physical or emotional abuse of caregiver by
patient
activities of daily living
Outcomes
Knowledge
Behavior
Status
1
No Knowledge
Never Appropriate
Extreme Signs and
Symptoms
2
Minimal
Knowledge
Rarely Appropriate
Severe Signs and
Symptoms
3
Basic Knowledge
Inconsistently
Appropriate
Moderate Signs and
Symptoms
4
Adequate Knowledge
Usually Appropriate
Minimal Signs and
Symptoms
5
Superior Knowledge
Consistently
Appropriate
No Signs and
Symptoms
Review of Omaha System Research
(1982 – 2003)
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Describe client problems
Describe clinical practice
Describe client 0utcomes
Explore health care utilization
Advance classification research
Involves students
Report on the Community Nurse Organization
project
• Completed not yet published (in 2005)
Bowles, K.H. (2005). Omaha System in Nursing Research. In In K.S. Martin (Eds.), The Omaha
System (2nd Ed.). (x). Philadelphia, PA: Elsevier Science.
2005 Summary
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Omaha System increases understanding various
populations and practices
• Relationship among client problems, nursing care and
client outcomes
– Predictions about health care resource utilization
– Advances the science of nursing classification
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Most studies were small, descriptive, or correlational
with a few quasi-experimental or predictive designs
Focus - mostly older adults in home care, public health,
community based clinics or nursing centers, hospital,
and transitional care
Search Criteria
Searched MEDLINE and CINAHL for “Omaha System” 2005 –
2012; Omaha System website references
Inclusion criteria:
• Research
• Peer reviewed journals/ papers in conference proceedings
• English
Excluded criteria:
• Abstracts only, posters, quality improvement, news items,
websites, dissertations, student class projects (even
though they had IRB approval)
• Omaha System mentioned only, not a major contribution
Literature Search Results
• Number articles found – 132
• Number Omaha System studies - 44
• 24 - Practice
• 17 - Advance Classification/ use/ interoperability
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Mapping terminologies
NLP – compare text with SNL use of “other”
Bibliometrics – diffusion of SNL
Compare to other instruments / EBP guidelines i.e. OASIS, ICSI
• 3 – Both practice and classification/ use/ interoperability
• 3 - Unable to retrieve for this presentation
• This presentation represents a subset of all possible research
Populations
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Neighborhood – population health
Low income urban populations
MCH - prenatal / post-partum
Chronic illness (i.e. CHF, COPD, DM, other)
Elderly
Caregivers of children with fetal alcohol spectrum
disorder
Settings
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Nursing centers
Public health
Home health care
Outpatient rehabilitation
Ambulatory care
Public forums
Transition from hospital to home
Research Methods
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Descriptive
Content analysis
Mixed method
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Interviews of practitioners/ secondary analysis of data
Content analysis of records, combined with structured
instruments
Quasi-experimental
Randomized trials
Data mining – KDD
Research Issue – Content Analysis
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Brooten et al (2007) conducted randomized control trial to
looking at the effect of ANPs
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Content analysis using the Omaha System to more specifically
understand problems and interventions performed in caring for
women with high risk pregnancies
Useful for describing nursing problems and interventions
Provided evidence of what APNs did that mattered
Caley et al (2009) analyzed transcripts of public forums to
identify needs of caregivers of children with FASD
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Used the Omaha System S&S - Problems
Identify nursing needs sensitive to nursing interventions not
found using emergent coding and key word analysis
Omaha System Problems/ PRSO
• Dansky et al (2008) evaluated effectiveness of telehealth for
heart failure patients in a randomized field study
• Used the S&S of problems with the PRSO to measure symptoms
for Diet (sodium and fluid intake), medication effectiveness, and
physical activity
• Telehome care resulted in fewer symptoms compared with
controls, but NS
• Finkelstein et al (2006) evaluated the effectiveness of
telehealth in a 3-group RCT
• Coping skills, activities of daily living (ADLs), diet, medication,
circulation (for CHF subjects) and respiratory (for COPD
subjects)
• Nurses used EHR to chart, subset of data used for study
• Only significant difference was ADLs improved and lower costs
Comparison with Standardized
Instruments
• Yu & Lang (2008) – two-group comparative design of
outpatient rehabilitation problems, interventions, and outcomes
between clients with and without cognitive impairment
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CARE program – University of Pennsylvania
201clients, Interprofessional rehabilitation care
Traditional research instruments, second study used EHR data
Similar outcomes – comparing FIMS with Omaha System NMS
and PRSO
• Different patients if using MMSE and OS Cognitive problem –
measure different S&S
• Recommendation is to compare trusted research instruments
with SNL – Definitions, terms
EHR/ Information Systems
• Primary or secondary use of data sets for research as a bi-product of
previous research or clinical care
• Can be more cost-effective data collection for research
• Lu & Lin (2007) – secondary analysis of IS data, 422 elderly with DM
– 688 problems, 3,189 interventions
– Significant decrease in blood glucose
– Described problems/ interventions, but didn’t relate which influenced
outcome
• Hong and Lundeen (2009) – evaluated client characteristics,
problems, and interventions in a community nursing center
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3,963 clients with 9,839 encounters
9,836 nursing interventions
• Challenge is to go beyond describing care
Knowledge Discovery
Fayyad, U., Piatetsky-Shapiro, G., & Smyth, P. (1996). From data mining to knowledge discovery in databases. AI
Magazine, pp. 37 – 54. http://www.kdnuggets.com/gpspubs/aimag-kdd-overview-1996-Fayyad.pdf. P. 41
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Rules for CDS
2,065 episodes of care
Westra, Dey et al (2011)
Rules for CDS
2,065 episodes of care
Westra, Dey et al (2011)
Rules for CDS
2,065 episodes of care
Westra, Dey et al (2011)
Generating New Questions
Complexity of
Data
KDD
Clustering
Interventions
Monsen, K., Westra, B.L., Yu, F., Ramadoss, V.K. & Kerr, M.J. (2009). Data Management for Intervention Effectiveness
Research: Comparing Deductive and Inductive Approaches, Research in Nursing and Health, 32(6) 647-656.
Comparative Effectiveness Research
• Mixed methods – data mining and traditional statistics
• Four intervention data management approaches –
• Frail vs Non-Frail elderly
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Omaha System Action Category
Theoretical groups
Clinical expert consensus groups (similar to CCS by AHRQ)
Data-driven intervention management groups
• Data driven approach best fit – weak evidence (AUC .544 to
.627 for frail elderly, .526 - .603 for non-frail elderly)
• There were differences in interventions for frail and non-frail
elderly.
• Different approaches may influence new knowledge
Monsen, K. A., Westra, B. L., Oancea, S. C., Yu, F., & Kerr, M. J. (2011). Linking home care interventions and
hospitalization outcomes for frail and non-frail elderly patients. Research in Nursing & Health, 34(2), 160-168.
Looking for Patterns:
Do PHNs Tailor Interventions?
Monsen, K.A. (2012, Publication in process
PHN Signature Styles?
Monsen, K.A. (2012, Publication in process
Standardizing Processes
EBP Guidelines
• Monsen, Neely et al (2012) – demonstrated the feasibility of
encoding existing guidelines using the Omaha system
• Improve interoperability, retaining nurse friendly terms
• Institute for Clinical Improvement (ICSI) guideline for
depression
Intervention
Problem
Category
Target
Care Description
Asthma EBP guideline
Monsen et al (2011)
Classification, Effective Use,
Other Uses
• Mapping to terminology/ instruments
• NLP to analyze “other” textual data to determine if OS is
used correctly
• Feasibility of integrating data across agencies & vendors
• Effective use of terminology – NLP studies
• Methods of data reduction into meaningful patterns
• EHR issues – consistency in documentation, missing data
• Time and motion studies to understand activities nurses
perform and the amount of time required
• Categorize nurse management interventions – staff and
groups are considered as “client”
Overall Summary of Findings
• Omaha System useful to describe nurse-sensitive problems in
multiple populations
• Beginning evidence about the relationship of nurse-sensitive
problems, nursing interventions, and a variety of outcomes
• Omaha System is useful for research in a variety of
community-based settings, populations
• Many studies are still descriptive, though an increasing number
are correlational, quasi-experimental, and RCT
• Use of large complex data sets allows us to see new patterns
to discover what nurses do that matters
Summary from Methods
• Interoperability of Omaha System data
• Technical interoperability – EHRs/ Agencies
• Semantic interoperability
• Processes interoperability
• Reuse of data is invaluable for discovering knowledge in
data bases from complex data
• UMN & KU: CTSA – nursing data is part of the clinical
data warehouse in process
U of Minnesota
AHC Information Exchange (AHC IE)
cwd 2012
Research Recommendations
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Use standardize processes as well as standardized data
Increase use of NLP to semi-automate content analysis
of textual data
Expand use of data mining for knowledge discovery in
databases – practice-based evidence
Expand coding of EBP guidelines, embed into EHRs and
evaluate effectiveness
Thank you, for further information:
Bonnie L. Westra, PhD, RN, FAAN, FACMI
Associate Professor / Co-Director Center for Nursing Informatics
University of Minnesota, School of Nursing
W - 612-625-4470
westr006@umn.edu
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