Integration of Nursing Informatics,
Nursing Classification Systems, and
Nursing Practice
(Nur 603)
Presenter:
Russell McGuire, MSN, RN
Director of Clinical Services, DHS
Appalachian Regional Healthcare, Inc.
Appalachian Regional
Healthcare
 History
 Formed
out of old UMWA hospital system
 Home health services 1968
 Current organization
8
hospitals
 16 primary care clinics and centers
 8 home health agencies and branches
 Long-term care
 DME
ARH System Center – Home
Services
 32,000
visits in 1969
 Over 450,000 for FY 97-98
 Services provided in 2 state region
 Eastern
Kentucky
 Southern west Virginia
Nursing Informatics
Nursing Informatics - Definition

“The use of technology and/or a computer system
to collect, store, process, display, retrieve, and
communicate timely data and information in and
across health care facilities that:
 Administer
nursing services and resources;
 Manage the delivery of patient and nursing care;
 Link research resources and findings to nursing
practice;
 Apply educational resources to nursing education”
(Saba, 1996).
Nursing Informatics - Focus
 Nursing
informatics focuses on the use of
“nursing information system” (NIS) to
administer nursing resources:
 To
assist in effective information management;
 Monitor the quality, effectiveness, and
outcomes associated with the provision of care;
 Protect the confidentiality and privacy of
patient data.
Conceptual Framework
Nursing Process
Data
Information
(raw facts)
(interpreted facts)
Atomic level
Information and
Communication Technology
Knowledge
(synthesized information)
Synthesis
Nursing Classification Systems
Reasons for Classification System
Development







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To standardize nomenclature
To expand nursing knowledge
To develop information systems
To teach decision making
To determine nursing costs
To allocate nursing resources
To communicate nursing to non-nurses
To link nursing knowledge
Source: McCloskey, J. & Bulechek, G. (1996) Nursing intervention classification.
Mosby Publishers)
Relevant Background

Basic concepts for information systems:
 Nursing data: refers to unstructured raw facts; Are
discrete entities; Lack interpretation. Forms the
basis for a nursing information system.
 Nursing information: data that has been given form
and has been interpreted.
 Nursing knowledge: synthesized information
derived from the analysis of data that has been
processed.
Relevant Background
 Nursing
 needed
Data Standards
for the management, documentation
and communication of nursing diagnosis,
interventions, and outcomes (patient and
nursing sensitive).
 researched and supported by the ANA
Council on Computer Applications in
Nursing and the NLN’s Council for Nursing
Informatics.
History
1970: ANA recommends that “nursing process” be
used as the standard for documenting nursing
practice.
 1970s: Nursing Diagnoses researched and
approved by the North American Nursing
Diagnosis Association (NANDA).
 1980: ANA’s Social Policy Statement - “Nursing
is the diagnosis and treatment of human responses
to actual or potential health problems”.

History
1985: Nursing Minimum Data Set (NMDS)
researched/developed by Werley and Lang.
 1986: ANA approves polices to develop a
classification system designed for all nursing
practice settings.
 1988: ANAs Broad of Directors accept the
NANDA Taxonomy I Revised.

History
 1988: ANA endorses
the Conference on Research
Priorities in Nursing Science. Identified two
needs:
 “the
need for standardized data sets which document
nursing care process across settings and a taxonomy to
classify nursing phenomena and allow the common use
of terms”.
 1990: ANA House
of Delegates recognizes the
Nursing Minimum Data Set (NMDS).




describes the nursing care of patients and their caregivers in a
variety of settings.
provides comparability across clinical settings.
demonstrates trends in nursing care.
provides data for policy research and policy decisions.
History

1991: ANA Congress of Nursing Practice
mandated the formation of the Steering Committee
on Databases to Support Clinical Nursing Practice.
 Purposes:
 propose
policy and program initiatives regarding
nursing classification systems.
 build a national database for clinical nursing
practice.
 coordinate public and private development of
databases.
History

1992: ANA Database Steering Committee
formally recognizes four nursing vocabularies:
 NANDA -
North American Nursing Diagnoses
Association.
 The Omaha System - Omaha VNA (Martin &
Scheet)
 Home Health Care Classification System Georgetown University (Saba).
 Nursing Intervention Classification - University of
Iowa (McCloskey & Bulechek)

1993: Development of the International
Classification of Nursing Practice.
Rationale: “Next Generation Nursing
Information Systems: Essential Characteristics for
Professional Practice”
Nursing information systems exists within the
context of the total continuum of the
“integrated patient record system”.
 Health care is and will continue to be an
information-intensive endeavor.
 Information is a critical resource in the health
care delivery environment.
 Nursing Practice is essentially an informationprocessing activity.

Rationale
 Nursing
information is essential to the
accuracy of integrated systems (both
health care delivery and information
systems).
 Patient-specific data are the focal point of
a totally integrated patient-record
system.
 Atomic-level data, captured within a
Nursing Information System will be used
for many purposes.
Users
Data/Information
World health officials
Policy makers, Researchers
Lawmakers
General health status and
health-related needs
of individual nations.
Scope
Worldwide
Data
ABSTRACTED, SUMMARIZED, AGGREGATED
Policy makers
Lawmakers, researchers
Insures
Trends in incidence, prevalence,
outcomes, and costs by region, by
diagnosis, by type of agency.
Nationwide
Data
ABSTRACTED, SUMMARIZED, AGGREGATED
Analysts, researchers,
Quality management,
Public health officials
Comparisons of treatments, outcomes,
and costs by locality and by agency.
Incidence and prevalence of diagnosis by region.
Community/
Region-wide
Data
ABSTRACTED, SUMMARIZED, AGGREGATED
Administrators,
Researchers, Accreditors
Quality managers
Costs of care by category of patient.
Number of patients admitted with specific diagnosis.
Volume of tests, procedures, interventions, outcomes.
Agency-wide
Data
ABSTRACTED, SUMMARIZED, AGGREGATED
Caregivers
Agency departments,
Quality managers, Insurers
Atomic level patient-specific data: e.g..assessments,
diagnoses, interventions, diagnostic test results, procedures,
treatments, hours of care, outcomes.
Individual
Patient
Data
Rationale
 Data
and data elements required for
nursing information systems are
evolving.
 To ensure high-quality practice, nurses
need access to sources of data that are
”beyond institutional, patient-specific
data”.
 “There will always be a need for human
interpretation of computer-processed
data”.
Where is all this Leading?
Unified Medical Language System
1986: National Library of Medicine initiates the
Unified Medical Language System (UMLS).
 Goal: to develop a computer-based information
resources for health professionals.
 designed to link information resources

 scientific
literature
 computer-based patient records
 factual databases
 expert systems
 other health related databases
Where Is All This Leading?
Unified Medical Language System

Three resources related to the UMLS:
 Metathesaurus - set of terms and concepts
associated with several biomedical
vocabularies.
 Semantic network - links the Metathesaurus
vocabularies together using semantic concepts.
 Information sources map - a description of
available databases.
Where Is All This Leading?
Unified Medical Language System
Using the same concept, the NLM is linking the
recognized nursing vocabularies (primarily for this
discussion NANDA, NIC, and NOC).
 This process of recognition and inclusion of
nursing vocabularies, taxonomies, and
classification schemes into the NLMs
Metathesaurus can been demonstrated in the
development of the unified nursing language
system.

Where Is All This Leading?
Unified Nursing Language System
 ANA database
steering committee developing a
common nursing language known as the unified
nursing language system (UNLS).
 Criteria for inclusion in the UNLS:
 Clinically
useful for making diagnosis, intervention,
and outcome decisions.
 Terms unambiguous, clearly and accurately defined.
 Tested for validated clinical use and reliability of
vocabulary terms.
 Accompanied by evidence of a process for periodic
review and appropriate methodology for research and
testing.
Where Is All This Leading?
Unified Nursing Language System
 To
date the ANA database steering committee has
recommended the four “recognized” nursing
classification schemes for inclusion in the UNLS.
 The UNLS will:
 Allow
for integration of patient data, scientific data, and
bibliographic data.
 Bring information to the bedside to improve clinical
decision making.
 Identify linkages and associations across vocabularies
and taxonomies.
 Linking clinical data, cost data, educational case data.
Are you ……
NANDA,
NIC,
NOC,
Impaired ?
Integration Into Nursing Practice
ARH Experience With Nursing
Classification Systems
 Information
systems development.
 Need for standards-based, evidenced based
practice guidelines.
 Need for standardized language across the
continuum.
 Across
nursing practice settings.
 Integrated from a trans-disciplinary, integrated
healthcare delivery perspective.
ARH Experience With Nursing
Classification Systems
 ARH
reviewed the current literature related
to nursing classification systems.
 Review initiated in the information systems
department.
 Input from nursing executive staff (acute
care / home health).
ARH Experience With Nursing
Classification Systems

Nursing classifications reviewed.
 NANDA (north American
nursing diagnosis
association).
 NIC (nursing intervention classification).
 NOC (nursing outcomes classification).
 Omaha - home health nursing practice.
 HHCC - home health nursing practice.

Features, advantages, disadvantages for use in
ARH determined.
ARH Experience With Nursing
Classification Systems: NANDA
 NANDA
- north American nursing diagnosis
taxonomy I revised.
 Features.
 Research based development.
 133 nursing diagnoses applicable to different
practice settings.
 Continued research and expansion.
 Based upon the nine human response patterns,
forming the abstract conceptual level.
ARH Experience With Nursing
Classification Systems: NANDA
 Advantages.
 Comprehensive
listing of nursing diagnoses.
 National and international recognition.
 Disadvantages.
 Does
not address specific interventions or
outcomes.
ARH Experience With Nursing
Classification Systems: NIC
 NIC
- nursing intervention project (Iowa
project.
 Features.
 433
documented, researched nursing
interventions.
ARH Experience With Nursing
Classification Systems: NIC
 Advantages.
 Most
comprehensive listing of researched
nursing interventions.
 Documented linkages to AHCPR guidelines,
nursing diagnoses.
 Continued research efforts to establish linkages
to patient outcomes.
 Disadvantages.
ARH Experience With Nursing
Classification Systems: Omaha


Developed by the VNA of Omaha
Three classification schemes:
 Problem classification (40 client problems)
 Intervention classification (62 interventions)
 Health teaching, guidance, and counseling
 Treatments and procedures
 Case management
 Surveillance
 Problem rating scale
ARH Experience With Nursing
Classification Systems: HHCC



Developed by dr. Virginia Saba (Georgetown
university).
Consists of :
 Nursing diagnosis - 145.
 Nursing intervention - 160.
 Home care component - represents clusters of
functional, behavioral, physiological, and
psychological health care patterns.
Numerically coded for information system use.
Extended Health Enterprise Model
Managed
Care
Employers
Population
Network
Insurers
Regulatory
Agencies
Acute
Care
Inpatient
Outpatient
Emergency
Testing
Long Term
Care
SNF
Nursing Home
Home
Health
Prof.
Services
Clinics
Psych/
Rehab
Nursing
Physicians
Urgent Care
Mental Health
IV Pharmacy
Dental
Surgicenter
Substance Abuse
HME
Group Practice
Diagnostic Centers
Ancillary Services
Hospice
Preventive
Affiliated
Health Ed.
Services
Wellness
Emerging Health Network
Clinical Objectives
 Integrate
data from all provider settings in
the health system.
 Follow patient across the continuum of care.
 Provide clinicians with a consistent view of
patient status regardless of where services
are performed.
Emerging Health Network
Financial Objectives
Allow direct contracting with
employers/capitation.
 Track health care and costs throughout an
enterprise.
 Provide tools to manage a population.
 Provide utilization data to make informed
decisions.

 Improved
clinical care.
 Improved financial viability.
Traditional Homecare Model
Home Health Provider
• Skilled Nursing
• Non-Skilled Nursing
• Rehab Therapies
Home
Medical
Equipment
Provider
Home I.V. Provider
Pharmacy
Patient
Medicare
Medicaid
Private
Insurance
Today’s Homecare Model
Home Health
Home I.V. Provider
HME
Skilled Nursing
Non-Skilled Nursing
PPS
Pharmacy
HME
Rehab Therapies
Self-Insured
HMOs
PPOs
Medicare
Medicaid
Private Insurance
Population
Impact on the Homecare
Provider

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Managed competition.
Increased shift of patient
population from acute care.
Industry-wide consolidation of
providers and vendors.
Demonstrated outcomes require
automated data collection.
Reduction in reimbursement for
services provided.
Impact On Homecare
Organizations
New Clinical Expectations
 Clinical
skills to assess and treat higher
acuity patients.
 Homecare manager becomes case manager.
 Point of service data collection for outcomes.
Impact On Homecare
Organizations
New Information System
 Clinical
outcome data tracking.
 Practice guidelines formation and
tracking.
 Customer satisfaction tools.
 Provider profiling.
 Provider performance.
KEY TO SUCCESS
 Clinical
excellence
Care Design
Problems/
Outcomes
The Care Design/ Pathway Should Represent a Benchmark of Care Which
Can Be Adapted to Specific Practices or Demographics.
Care Design
Problems/
Outcomes
Interventions/
Activities
The Care Design/ Pathway Should Represent a Benchmark of Care Which
Can Be Adapted to Specific Practices or Demographics.
Care Design
Problems/
Outcomes
Interventions/
Activities
Diagnosis
ICD-9
The Care Design/ Pathway Should Represent a Benchmark of Care Which
Can Be Adapted to Specific Practices or Demographics.
Care Design
Problems/
Outcomes
Interventions/
Activities
Diagnosis
ICD-9
Level of
Severity /
Disease
The Care Design/ Pathway Should Represent a Benchmark of Care Which
Can Be Adapted to Specific Practices or Demographics.
Care Design
Physical
Problems/
Variables
Outcomes
Non-Physical
Interventions/
Variables
Activities
Diagnosis
ICD-9
Level of
Severity /
Disease
BENCHMARK
PATHWAY
The Care Design/Pathway Should Represent a Benchmark of Care Which
Can Be Adapted to Specific Practices or Demographics.
Care Design
Benchmark
Purpose:
To Establish a Standard of Care As It Relates to a
Specific Diagnosis, Level of Severity and
Treatment.
Ultimate Goal
Actual
Prescribed
Ideal
Benchmark



Actual - Services/Treatments/Supplies/Drugs Actually Used in Total
Treatment Plan.
Prescribed - Services/Treatments/Supplies/Drugs Prescribed by
Attending Physician.
Benchmark - Established Norm of Services Treatments/
Supplies/Drugs Based on Diagnosis and Level of Severity/Disease
McKesson HBOC Pathways
Homecare - Unique Features

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Complete solution-all homecare service lines.
Integration with McKesson HBOC products.
Integration of financial and clinical homecare applications
and data.
Integration of data from all disciplines in the homecare
arena promoting automated collaborative care.
Discrete/structured data capture.
Intuitive GUI supporting both non-technical and
experienced end users.
Designed by experienced homecare clinicians.
McKesson Pathways
Homecare - Unique Features



Automation of documentation process
 Assessment/vitals
 MAR and IV administration
 Clinical pathways and care plans
 All HCFA forms become by product of collected information
Severity indexing tool
 Weighted questions
Starter kit to build care designs/care plans
 Sample interdisciplinary clinical pathways
 Library of treatment interventions, outcome goals, and staging
questions
 Library of assessment data
McKesson HBOC Pathways
Homecare - Benefits
Clinical benefits.
 Reduction in time generating appropriate paperwork (i.E.
HCFA 485).
 Access to current and historical organized patient
information .
 Increased communication through automated collaborative
care.
 Ability to measure patient specific clinical outcomes.
 Ability to develop and customize interdisciplinary care
designs and care plans.
Pathways Homecare
Technical Requirements
POC support
 Store and forward
 Laptops
Connectivity
 Dial-up via a modem
Hardware/operating
system/RDBMS
 Sequeal server