A knowledge-based patient assessment system: conceptual and technical design.

This paper describes the design of an inpatient patient assessment application that captures nursing assessment data using a wireless laptop computer. The primary aim of this system is to capture structured information for facilitating decision support and quality monitoring. The system also aims to improve efficiency of recording patient assessments, reduce costs, and improve discharge planning and early identification of patient learning needs. Object-oriented methods were used to elicit functional requirements and to model the proposed system. A tools-based development approach is being used to facilitate rapid development and easy modification of assessment items and rules for decision support. Criteria for evaluation include perceived utility by clinician users, validity of decision support rules, time spent recording assessments, and perceived utility of aggregate reports for quality monitoring.

Mapping nursing diagnosis nomenclatures for coordinated care.

PURPOSE: To map the problem or diagnosis terms from three nomenclatures, term to term, to determine commonalities and differences; and to determine whether it is possible to develop a single vocabulary that contains the best features of all. When different nomenclatures are used in different settings, continuity of care is hampered by the need to re-state problems and interventions. DESIGN: The sample for this descriptive analysis was 396 terms from three nursing diagnosis and problem nomenclatures recognized by the American Nurses Association: the North American Nursing Diagnosis Association (NANDA) Approved List, the Home Health Care Classification (HHCC), and the Omaha System. METHOD: Terms from each of the three nomenclatures were mapped to terms in each of the others. Consensus methods were used to resolve differences in mapping decisions. Terms were characterized as "Same," "Similar," "Broader," "Narrower," and "No Match." Validation of consistency and accuracy was done by reverse mapping, use of syllogisms, use of taxonomic groupings, and expert review. RESULTS: Of 396 terms, 21 concepts accounting for 63 terms were found to be the same or similar in all three nomenclatures; 91 terms were unique to the nomenclature in which they were found ("No Match"). The remaining 242 terms had a narrower or broader relationship to at least one term in another nomenclature. In all three nomenclatures, inconsistencies existed in level of abstractness of the diagnosis or problem terms, and in definition and placement of terms within their own taxonomic structure. CONCLUSION: Because of differences in structure and incompatible taxonomic arrangements, a master list of "preferred terms" taken from the three nomenclatures is not feasible. However, the mappings are useful for determining commonalities and the unique contributions of each nomenclature, which can facilitate the development of a uniform language for nursing diagnoses. The mapping can also form the basis for automatic translation of computer-stored nursing diagnoses from one setting to another when different nomenclatures are used.

ANA standards for nursing data sets in information systems.

The American Nurses Association has established the Nursing Information and Data Set Evaluation Center. The purpose of this Center is to develop and disseminate standards pertaining to information systems that support the documentation of nursing practice, and to evaluate voluntarily submitted information systems against these standards. The need for an evaluation center arises out of a long history of calls for standards pertaining to nursing data and information systems. These calls have come from the Secretary of Health and Human Services Commission on Nursing, the National Commission on Nursing Implementation Project, and a joint Task Force appointed by the Congress of Nursing Practice Steering Committee on Databases to Support Clinical Nursing Practice and the Congress of Nursing Practice Committee on Nursing Practice Standards and Guidelines. Standards have been developed to evaluate the completeness, accuracy and appropriateness of four dimensions of nursing data sets and the systems that contain them: (1) nomenclature, (2) clinical content, (3) clinical data repository, and (4) general system characteristics.

Online practice guidelines: issues, obstacles, and future prospects.

The "guidelines movement" was formed to reduce variability in practice, control costs, and improve patient care outcomes. Yet the overall impact on practice and outcomes has been disappointing. Evidence demonstrates that the most effective method of stimulating awareness of and compliance with best practices is computer-generated reminders provided at the point of care. This paper reviews five steps along the path from the development of a guideline to its integration into practice and the subsequent evaluation of its impact on practice and outcomes. Issues arising at each step and obstacles to moving from one step to the next are described. Last, developments that could help overcome the obstacles are highlighted. These include 1) more rapid knowledge acquisition using data mining, 2) better accommodation to imprecise knowledge in clinical algorithms using fuzzy logic, 3) development of a shareable model for guideline representation and execution, and 4) more widespread availability of clinically robust information systems that support decision-making at the point of care.

Nursing data, classification systems, and quality indicators: what every HIM professional needs to know.

The nursing profession has developed a number of classification systems. What can HIM professionals learn from the processes and results? This article presents an overview of the major nursing classification systems and examines some of the national efforts to standardize nursing data elements.

P-CAPE: a high-level tool for entering and processing clinical practice guidelines. Partners Computerized Algorithm and Editor.

The Partners Computerized Algorithm Processor and Editor (P-CAPE) is a high-level tool intended to remove the programming bottleneck for implementing practice guidelines in our computer-based record system, and to integrate guideline-based advice into the clinician's workflow. P-CAPE has three major components: 1) An Editor that allows an analyst to enter the parameters of a guideline in the form of an algorithm; 2) A Navigator that processes the steps of the guideline and logs all transactions in a patient-specific file; and 3) A clinician Notifier that sends messages to a patient's covering clinician, seeking data or presenting recommendations and order sets that can be processed by the system. P-CAPE's guideline object model was adapted from the InterMed Collaboratory GuideLine Interface Format (GLIF).

Setting standards for nursing data sets in information systems.

The American Nurses Association (ANA) has established the Nursing Information and Data Set Evaluation Center (NIDSEC). The purpose of this Center is to develop and disseminate standards pertaining to information systems that support the documentation of nursing practice, and to evaluate voluntarily submitted information systems against these standards. The need for an evaluation center arises out of a long history of calls for standards pertaining to nursing data and to information systems. Standards have been developed to evaluate the completeness, accuracy and appropriateness of four dimensions of nursing data sets and the systems that contain them 1) nomenclature, 2) clinical content, 3) clinical data repository, and 4) general system characteristics. Once the standards and scoring mechanisms were established, they were tested for reliability and validity. A Content Validity Index (CVI) of 0.875 was established for the scoring tool.

Setting a national research agenda in nursing informatics.

An active program of research assures the development and evaluation of nursing informatics solutions to the challenges of contemporary patient care. Experts in nursing informatics research participated in a two-part electronic mail survey of research priorities. Priorities identified included formalization of nursing vocabularies, design and management of databases for nursing information, development of technologies to support nursing practice, use of telecommunications technology in nursing, patient use of information technology, identification of nurses' information needs, and systems modeling and evaluation. Many of these priorities are similar to those advanced in the 1993 US PHS NINR PEP Report on Nursing Informatics. Additionally, the findings suggest the need for greater emphasis on the application of emerging technology to nursing practice problems, and the expansion to consider patients as direct users of information systems.

Components of the optimal ambulatory care computing environment.

We present here a framework of core components of an ambulatory care computing environment, based on clinical and functional needs and workflow scenarios. We have established this framework through the use of two study devices: a vision of the clinical office of the future, and a survey of possible computer applications, both designed to help clinicians and practice directors communicate their information needs to systems designers. Clinicians prioritize applications based on strategic and practice goals: support for clinical users' workflow, improved quality of care, reduced cost of care, and the ability to measure performance and status. By reorganizing the needed functionality from a clinical viewpoint into a technical viewpoint, we are able to identify core information components for systems design. Based on this analysis, information needs in the ambulatory environment can be divided into five primary functions: patient data retrieval, documentation, communication, knowledge resources, and aggregate reporting. Three other fundamental processes--knowledge-based interventions, information integration, and confidentiality--run through all of these front-line functions. Component applications and data structures built with this framework in mind will afford a maximum combination of functionality and flexibility to handle future changes in the clinical environment.

Evaluation of a decision support system for pressure ulcer prevention and management: preliminary findings.

A decision support system for prevention and management of pressure ulcers was developed based on AHCPR guidelines and other sources. The system was implemented for 21 weeks on a 20-bed clinical care unit. Fifteen nurses on that unit volunteered as subjects of the intervention to see whether use of the system would have a positive effect on their knowledge about pressure ulcers and on their decision-making skills related to this topic. A similar care unit was used as a control. In addition, the system was evaluated by experts for its instructional adequacy, and by end users for their satisfaction with the system. Preliminary results show no effect on knowledge about pressure ulcers and no effect on clinical decision making skills. The system was rated positively for instructional adequacy, and positively for user satisfaction. User interviews related to satisfaction supplemented the quantitative findings. A discussion of the issues of conducting experiments like this in today's clinical environment is included.

Nursing Information and Data Set Evaluation Center.

The American Nurses Association (ANA) has established the Nursing Information and Data Set Evaluation Center (NIDSEC). The purpose of this Center is to develop and disseminate standards pertaining to information systems that support the documentation of nursing practice, and to evaluate voluntarily submitted information systems against these standards. The target audience for these standards includes both consumers and vendors of clinical information systems. The need for an evaluation center arises out of a long history of calls for standards pertaining to nursing data and to information systems. These calls have come from the Secretary of Health and Human Services Commission on Nursing, the National Commission on Nursing Implementation Project (NICNIP). Standards will be developed to evaluate the completeness, accuracy and appropriateness of four dimensions of nursing data sets and the systems that contain them: 1) Nomenclature; 2) Clinical Content; 3) Clinical Data Repository; and 4) General System Characteristics.

A knowledge-based decision support system for prevention and treatment of pressure ulcers.

As part of a research project intended to provide problem-based knowledge to clinicians at the point of care, we have developed a system that supports the nurse's development of patient-specific, guideline-based treatment plans for patients who have pressure ulcers or are at risk for developing them. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Knowledge is accessible to the user via: 1) hypertext links from the data entry screens; 2) explicit entry into an indexed version of the guideline; 3) imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Data on 113 patients were entered during the 21-week experimental period. The system is being evaluated for its instructional adequacy, its impact on clinicians' decision-making and knowledge, and on processes of care. Users' perceptions of the system are also being evaluated. Dissemination issues in the context of today's health care environment are addressed.

A decision support system for prevention and treatment of pressure ulcers based on AHCPR guidelines.

We have developed a Pressure Ulcer Prevention and Management System to assist clinicians with patient-specific decision making. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Guideline-based knowledge is imbedded into the system, and is accessible in several ways: 1) via hypertext links from the data entry screens; 2) via explicit entry into an indexed version of the guideline; 3) via imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) via explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Preliminary usage data are provided. Issues with rendering guideline material useful for patient-specific decision support are discussed. In our setting, these issues had to do with a) incongruity with local standards; b) insufficient specificity; and 3) insufficient comprehensiveness. Issues of use and dissemination in the context of today's health care environment are also addressed.

Capturing and using clinical outcome data: implications for information systems design.

There is an urgent need to capture and record data related to clinical outcomes, but there are many barriers. The range of problems includes lack of agreement on conceptualization of the term "outcome," inadequate measures of outcomes, and inadequate information systems to capture and manipulate data that would reflect outcomes. This article focuses on information system requirements to capture, store, and utilize clinical outcome data. For greatest accuracy, outcome data should be captured as close to the source as possible, including direct data capture from patients themselves and from their families. To make maximum use of outcome data, systems must be designed to 1) store data in multipurpose databases; 2) share data across different platforms; 3) link outcome data to other data that might influence or explain outcomes; 4) allow querying of the data by authorized personnel; and 5) protect patient confidentiality.

Evaluation of a problem-based access knowledge system using triangulation methods.

A microcomputer-based system designed to provide nurses and physicians access to expert synthesized knowledge in the area of pulmonary arterial waveform troubleshooting has been developed and implemented. Evaluation using triangulation methods show that there was a substantive increase in knowledge in both nurses and physicians.¿.

Toward a uniform language for nursing in the US: work of the American Nurses Association Steering Committee on databases to support clinical practice.

This paper reports on the work of the American Nurses Association Steering Committee on Databases to Support Clinical Practice, in existence since 1989. Responding to its broad charges, the Steering Committee has laid down the foundations for its work in declaring the nursing process as the framework for nursing data in database systems, and in endorsing the Nursing Minimum Data Set as the set of minimum elements for any system designed to carry health-related data that reflects nursing care. In addition, the Steering Committee has begun initiatives to: 1) promote the inclusion of nursing-related data in large health-related databases, and 2) develop a Uniform Language for nursing through a phased approach. The Steering Committee also works directly with the International Council of Nurses to promote the inclusion of nursing data in internationally used classification systems and to develop an international language that describes nursing care.

Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice.

The American Nurses Association (ANA) Cabinet on Nursing Practice mandated the formation of the Steering Committee on Databases to Support Clinical Nursing Practice. The Committee has established the process and the criteria by which to review and recommend nursing classification schemes based on the ANA Nursing Process Standards and elements contained in the Nursing Minimum Data Set (NMDS) for inclusion of nursing data elements in national databases. Four classification schemes have been recognized by the Committee for use in national databases. These classification schemes have been forwarded to the National Library of Medicine (NLM) for inclusion in the Unified Medical Language System (UMLS) and to the International Council of Nurses for the development of a proposed International Classification of Nursing Practice.

User evaluation: PA catheter waveforms troubleshooting system.

This paper reports on a user satisfaction survey of a system for consultation and education in troubleshooting pulmonary artery catheter waveforms. The twelve-item End-User Computing Satisfaction Questionnaire was used to assess users' ratings in four areas. On a scale of 1-5 (with 1 the lowest), the ratings were: Content, 3.5; Accuracy, 4.5; Format, 4.2; Ease of Use, 4.4, and Timeliness, 4.1. Comparison with ratings in a survey that included a variety of applications and settings is provided.