Required Information for the Patient Record: Nursing and Allied Health

1. Required Information for the Patient Record: Nursing and Allied Health Testimony to the NCVHS Terminology Hearings May 17-18, 1999

2. 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

3. 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

4. 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)

5. Purpose of PMRI • Reminder to providers • Communication among providers • Source of data for • payers • managers • researchers

6. Problems with PMRI • Idiosyncratic recording by clinicians: data difficult to • retrieve • interpret • aggregate • analyze • Clinicians and others require different concept representations.

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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

13. 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

14. 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

15. 22 Care Components(derived from HHCC) • Activity • Circulation • Cognition • Coping and Mental Health • Fluids and Electrolytes • Gastrointestinal Function • Health Knowledge and Behaviors

16. 22 Care Components (2) • Immunology • Medications and Blood Products • Metabolism • Nutrition • Physical Regulation • Pre-, Intra-, Post-Procedure • Respiration

17. 22 Care Components (3) • Role Relationships • Safety • Self Care • Self Concept • Sensation, Pain, and Comfort • Tissue Integrity • Tissue Perfusion • Urinary Elimination

18. AXES • Problems • Goals • Orders

19. Elements on Problems Axis • Subject • Object • Likelihood • Status • Degree • Duration • Value

20. Elements on Problems Axis (2) • Frequency • Body Site • Laterality

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

22. Elements on Goals Axis • Subject • Object • Performance • Level of Performance • Equipment • Manifestations • Goal Evaluation Status

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

24. Elements on Orders Axis • Subject • Object • Action • Indicators • Method • Risk Factors

25. 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.

26. 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

27. 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

28. Comparison to NIC • PCDS Orders compare in granularity to NIC Activities. • NIC developed by consensus process; PCDS derived from patient care documents

29. 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.

30. 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

31. Deliverables • Recommendations for further development • Guidelines / desiderata • Papers for publication • Presentations

32. Process • Briefing book • Learning about language & standards • Setting goals • Small group work toward goals • Reporting and disseminating

33. Financial Support • National Library of Medicine • Div. Of Nursing, HRSA • AMIA Nursing Informatics WG • American Medical Association • 3M • CareCentric Solutions • Cerner Corporation

34. Financial Support (2) • IDX • Kaiser Permanente • Lexical Technology • McKessonHBOC • Oceania • SMS • SNOMED International

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

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