Summer Institute in Nursing Informatics (SINI) 2006 Part II Item Type Poster/Presentation; Conference/Congress Authors Elias, Beth; Fortin, Debra; Olson, Carol, M.S.N., R.N.; Sowan, Azizeh Khaled; Barbosa, Sayonara; Seckman, Charlotte; Kraska, Sherri; Yapor, Janet; Lyle, Cynthia, R.N.; Sapnas, Kathryn; Gallagher Gordon, Mary; Ward-Presson, Ginger; Murphy, Judy; Saba, Virginia K.; Charters, Kathleen G.; Sensmeier, Joyce; Romano, Carol Ann; Skiba, Diane J.; Norton, Michele; Tourville, Sharon; Ozbolt, Judy G.; Moss, Jacqueline, Ph.D., R.N.; Bradley, Victoria; Detmer, Don E.; Kennedy, Patrick J. (Patrick Joseph), 1967- Publication Date 2006 Keywords Medical protocols; Nursing informatics; Patient Care; Medical Order Entry Systems Download date 05/10/2021 15:30:44 Item License https://creativecommons.org/licenses/by-nc-nd/4.0/ Link to Item http://hdl.handle.net/10713/3966 Advancing Clinical Practice Through Nursing Informatics 16th Summer Institute in Nursing Informatics University of Maryland School of Nursing July 19-22, 2006 Classifications Standards Virginia K. Saba, EdD, RN, FAAN, FACMI, LL Distinguished Scholar, Adjunct-GT Professor, Adjunct-USUHS . Informatics & Clinical Care Classification System (CCC) Consultant Objectives Discuss Nursing Classifications Including 12 ANA ‘Recognized’ Classifications. Highlight Healthcare Standards: National & International Standards Organizations Describe How a Standardized Coded Nursing Classification – CCC - is Used to Electronically Document Nursing Care via Clinical Pathway. Classification & Standard Uses Electronic Health Record (E.H.R.) Computer-Based Patient Record (C.P.R.) Document & Code Nursing Practice Aggregate & Compare Coded Data Across: Client Settings, Clinical Populations, Geographic Areas, Time Develop Evidence-Based Practices Nursing & Classifications Classification Confusion Classification: Vocabulary Arranged in groups/classes & hierarchical structure Vocabulary: List of Words/Terms re a specific topic/subject. Taxonomy: Classification with Levels & Types Nomenclature: Combinatorial Vocabulary (e.g. axes) based on rules. Terminology: Set of Terms that Represent a System of Concepts 21st-Century Nurses Need Classifications Improve safety for patients Increase time for direct patient care Reduce paperwork Research-based evidence for disease management Cost-effective case management Compliance with regulatory and payer requirements Patient : Classification Codes DIAGNOSIS INTERVENTION OUTCOME MD initial dx, coded surgery/procedures, coded discharge dx, coded drugs itemized, coded days in hospital itemized, coded PT initial modalities itemized, coded discharge measurements, measurements, not coded not coded RN nsg diagnosis, assessment forms goals met, not coded daily notes not coded nsg problem list, treatment records not coded care plans med administration records transfer forms team conference discharge instructions not coded ANA Classification Initiatives 1970 - Nursing Process 1988 - NANDA Taxonomy I Revised 1990 - Nursing Minimum Data Set 1992 - Recognized 4 Nursing Classifications 1994 – Classifications in UMLS (NLM) 1995 – 1999 Recognized 9 Other Classifications ANA Recognized 1st 4 Nursing Classifications NANDA – North American Nursing Diagnosis Association OMAHA System CCC – Clinical Care Classification (Previously HHCC) NIC – Nursing Intervention Classification NANDA Taxonomy II North American Nursing Diagnosis Association (NANDA) 1973-1975-37 Diagnostic Labels 1996- 2001 Taxonomy I:104-150 labels 2005/6 – Taxonomy II : 172 Labels <Impaired Physical Mobility (ooo85)> OMAHA System Omaha VNA & Karen Martin Community-focused taxonomy consists of three schemes: 40 Client Problems Classified ( 4 domains, 63 Interventions (4 categories), & Problem-Rating Scale for Outcomes (3 concepts (Knowledge, Behavior, Status) <Physical Activity> Problem (37) <Positioning> Intervention (42) Clinical Care Classification System (2.0) (Preciously HHCC) Virginia Saba & Colleagues CCC of 182 Nursing Diagnoses & 3 Outcomes ( 546) CCC of 198 Nursing Interventions & 4 Actions (792) Classified by 21 Care Components Documents Essence of Care <Improve Physical Mobility --> Teach Cane Walking --> Mobility Improved> Nursing Intervention Classification (NIC) (4.0) McCloskey & Bulecheck (IOWA) NIC list of 514 intervention labels, grouped by 44 Specialty Areas, & 7 domains. To Depict Range of Nursing Activities <Activity Therapy (4310 )> (Has 27 Associated Activities/Not Coded) Unified Medical Language System (UMLS/NLM) 1996 – NLM Integrated ANA’s 4 Nursing Classifications into Metathesaurus of Unified Medical Language System (UMLS) All ANA Recognized Classifications Used Same Process ANA Recognized 2nd 6 Nursing Classifications NOC – Nursing Outcome Classification PNDS -- Perioperative Nursing Data Set NMDS – Nursing Minimum Data Set NMMDS – Nursing Management Minimum Data Set ICNP – International Classification of Nursing Practice Nursing Outcome Classification (NOC) Johnson & Maas, IOWA NOC is a comprehensive list of 330 patient outcomes with multiple levels (5) & grouped into 8 categories. To Evaluate Effects of Nursing Interventions <Mobility Level (0208)> (Has 8 Indicators & 5 levels) Peri-operative Nursing Data Set (PNDS) AORN (American Operating Room Nurses) Consists of a Subset of NANDA Diagnoses, Nursing Interventions & Outcomes <Verifies Operative Procedure> Nursing Minimum Data Set (NMDS) 16 Data Elements ( Dr. H. Werley) Nursing Care (4) Nursing Diagnosis Nursing Interventions Nursing Outcomes Intensity of Nursing Care Patient Demographics (5) Services (7) Nursing Management Minimum Data Set (MMDS) Describes Patient/Client Population Services by Nursing Delivery Unit/Service Specialty Developmental Focus Interaction Focus Population Focus International Classification of Nursing Practice (ICNP) 1.0 ICN (International Council of Nursing) Nursing Practice – Uses 7- Axis Model To Create Nursing Diagnoses (Focus), Interventions (Actions), & Outcomes Focus - Psychomotor Activity (10016008) Action – Offering (10013636) ANA Recognized 3rd 3 Nursing Classifications SNOMED CT – Systematized Nomenclature of Combined Terminology ABC Codes – Complimentary & Alternative Medicine (CAM) LOINC – Logical Observation Identifier Names & Codes SNOMED Combined Terminology (CT) College of American Pathologists Over 137,000 terms in 11 Clinical Modules SNOMED CT = Read CC (UK) + RT Codes Integrating Nursing Classifications: CCC, NANDA, Omaha, NIC, & NOC Nursing Terminology Agreements NANDA Nursing Interventions Classification Nursing Outcomes Classification Home Health Care Classification Omaha System PeriOperative Nursing Data Set (PNDS) ABC Codes Complimentary & Alternative Medicine & Conventional Nursing Osteopathic Doctors Integrated 3 Nursing Classifications – CCC, NIC, Omaha <Urinary Tube Care, General, Intervention> LOINC Laboratory Test Results Expanded to Patient Measurements e.g. Blood Pressure, Symptoms, Outcomes etc. Includes over 32,000 Terms Uses CCC Nursing Diagnoses Outcomes Other HealthCare Classifications AMA - CPT (Current Procedure Terminology HCPC - Health Care Financing Administration NDC - National Drug Classification DSM-IV – Mental Disorders World Health Organization (WHO) International Classification of Diseases (ICD) ICD – 9 ICD – 9 CM/3vols ICD – 10 ICPC – Primary Care ICF – International Classification of Functioning, Disability, & Health Highlight Standards / National & International Definitions of Standards Is a yardstick rule, principle, established by law Provide rules, guidelines, or characteristics Conforms to an established law or custom Approved by an official recognized body Healthcare Standards Organizations American National Standards Institute Healthcare Informatics Systems Board (HISB) Healthcare Information Technology Standards Panel (HITSP) American Society for Testing & Materials (ASTM) Health Level 7 (HL7) National Committee on Vital & Health Statistics (NCVHS) International Standards Organization (ISO) ANSI HISB Coordination of Health Care Informatics Standards for Electronic Health Record (E.H.R) Systems including Communication of Healthcare Protocols HITSP Established 10-05 – To Harmonize Interoperability Standards Ongoing ASTM Developer of standards related to technical information including health- related computer-based systems Health Standards Committee – E31 <http:www.astm.org> Health Level 7 (HL7) Developer of standards for the exchange and integration of data that supports clinical patient care between computer- based systems. http:www.hl7.org NCVHS – DHHS Oversee DHHS Initiatives Sub Committee of Health Data Standards for HIPAA ANSI-HISB Provided DHHS-Inventory of Clinical Informatics Standards Determined HIPAA Code Sets HIPAA of 1996 -Health Insurance Portability & Accountability Act To improve efficiency & effectiveness of the health care system by the electronic transmission of standardization health information. HIPAA - Phase 1: Patient Safety / Security / Privacy Electronic Data Interchange: ANSI / HL7 Identifiers -2: National Provider (SS#) & Employer Identifiers Code Sets for Data Reporting Code Sets for Electronic Reimbursement HIPAA - Phase 2: Patient Medical Record Information (PMRI) Documentation of Patient Care Core Code Sets:SNOMED/CT, LOINC, NDC, etc. SNOMED CT – Nursing Code Sets – CCC, Omaha, NANDA & NIC Map to Related Data Sets - ICD, CPT, HCPCS, DSM-IV, etc. Electronic Health Record (EHR) HHS Secretary