# Presentation: 049875

## Required Information for the Patient Record:  Nursing and Allied Health

- Testimony to the
- NCVHS Terminology Hearings
- May 17-18, 1999

## 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

## 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

## 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)

## Purpose of PMRI

- Reminder to providers
- Communication among providers
- Source of data for
- payers
- managers
- researchers

## Problems with PMRI

- Idiosyncratic recording by clinicians:  data difficult to
- retrieve
- interpret
- aggregate
- analyze
- Clinicians and others require different concept representations.

## 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

## 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

## 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

## 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.

## 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.

## 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

## 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

## 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

## 22 Care Components(derived from HHCC)

- Activity
- Circulation
- Cognition
- Coping and Mental Health
- Fluids and Electrolytes
- Gastrointestinal Function
- Health Knowledge and Behaviors

## 22 Care Components (2)

- Immunology
- Medications and Blood Products
- Metabolism
- Nutrition
- Physical Regulation
- Pre-, Intra-, Post-Procedure
- Respiration

## 22 Care Components (3)

- Role Relationships
- Safety
- Self Care
- Self Concept
- Sensation, Pain, and Comfort
- Tissue Integrity
- Tissue Perfusion
- Urinary Elimination

## AXES

- Problems
- Goals
- Orders

## Elements on Problems Axis

- Subject
- Object
- Likelihood
- Status
- Degree
- Duration
- Value

## Elements on Problems Axis (2)

- Frequency
- Body Site
- Laterality

## Example Problem Statement

- Patient has confirmed, chronic, moderately impaired range of motion (60% of normal) of left shoulder.

## Elements on Goals Axis

- Subject
- Object
- Performance
- Level of Performance
- Equipment
- Manifestations
- Goal Evaluation Status

## Example Goal Statement

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

## Elements on Orders Axis

- Subject
- Object
- Action
- Indicators
- Method
- Risk Factors

## 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.

## 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

## 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

## Comparison to NIC

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

## 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.

## 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

## Deliverables

- Recommendations for further development
- Guidelines / desiderata
- Papers for publication
- Presentations

## Process

- Briefing book
- Learning about language & standards
- Setting goals
- Small group work toward goals
- Reporting and disseminating

## Financial Support

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

## Financial Support (2)

- IDX
- Kaiser Permanente
- Lexical Technology
- McKessonHBOC
- Oceania
- SMS
- SNOMED International

## Offer

- Will provide formal report of the conference to the committee by end of summer

## Thank you.

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