Practice-Based Informatics Research

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1

Practice
-
Based Informatics Research


2012
State of the Science Congress on Nursing
Research, “Discovery through Innovation”

Bonnie L. Westra, PhD, RN, FAAN, FACMI

Associate Professor, University of Minnesota, School
of Nursing; Co
-
Director Center for Nursing Informatics


Objectives

1.
Describe the Omaha System.

2.
Summarize state
of the science
using
the
Omaha System research.

3.
Describe next steps
for advancing nursing
science with
Omaha System data.

Omaha System


Comprehensive, user friendly terminology, describes a
holistic view of health for individuals, families, and
communities


Originated in 1975, supported by multiple federal grants,
updated in 2005


Three components


Problem Classification Scheme


Intervention Scheme


Problem Rating Scales for Outcomes


Includes terms/ concepts, definitions, and codes

http
://
omahasystemmn.org/documents/2009_Omaha_System_concept_map.pdf

© K Monsen 2009

12,600

Environmental

Psychosocial

Physiological

Health Related
Behaviors

Income

Sanitation

Residence

Neighborhood/
workplace

safety

Communication
with community
resources

Social contact

Role change

Interpersonal
relationship

Spirituality

Grief

Mental health

Sexuality

Caretaking/
parenting

Neglect

Abuse

Growth and
development

Hearing

Vision

Speech and language

Oral health

Cognition

Pain

Consciousness

Skin

Neuro
-
musculo
-
skeletal
function

Respiration

Circulation

Digestion
-
hydration

Bowel function

Urinary function

Reproductive function

Pregnancy

Postpartum

Communicable/ infectious
condition

Nutrition

Sleep and rest
patterns

Physical activity

Personal care

Substance use

Family planning

Health care
supervision

Medication regimen

E
xample of Omaha System

Caretaking/parenting


providing support, nurturance,

stimulation
and physical care for dependent child or adult



difficulty providing physical care/safety



difficulty providing emotional nurturance



difficulty providing cognitive learning experiences and activities



difficulty providing preventive and therapeutic health care



expectations incongruent with stage of growth and development



dissatisfaction/difficulty with responsibilities



difficulty
interpreting or responding to verbal/nonverbal
communication



neglectful



abusive



other

Intervention Examples


Caretaking/ Parenting

Category

Target

Client Specific Data

CM

environment

Transitions in housing and levels of care

CM

finances

resources available to assist with financial
needs associated with caregiving

S

coping skills

manages challenges and changes

S

safety

physical or emotional abuse of caregiver by
patient

TGC

caretaking
/
parenting
skills

activities of daily living

TGC

continuity of care

coordination among providers and resources

TGC

coping skills

realistic expectations

Outcomes

Knowledge

Behavior

Status

1

No Knowledge

Never Appropriate

Extreme Signs and
Symptoms

2

Minimal

Knowledge

Rarely Appropriate

Severe Signs and
Symptoms

3

Basic Knowledge

Inconsistently
Appropriate

Moderate Signs and
Symptoms

4

Adequate Knowledge

Usually Appropriate

Minimal Signs and
Symptoms

5

Superior Knowledge

Consistently
Appropriate

No Signs and
Symptoms

Review of Omaha System Research

(1982


2003)


Describe client problems


Describe clinical practice


Describe client 0utcomes


Explore
health care
utilization


A
dvance
classification
research


Involves students


Report
on the Community Nurse Organization
project


Completed not
yet
published (in 2005)

Bowles, K.H. (2005). Omaha System in Nursing Research. In In K.S. Martin (Eds.),
The Omaha
System (2nd Ed.)
. (x). Philadelphia, PA: Elsevier Science.

2005 Summary


Omaha System increases understanding various
populations and practices


Relationship
among client problems, nursing care and
client
outcomes


Predictions
about health care resource
utilization


Advances the
science of nursing
classification


Most studies were small, descriptive, or correlational
with a few quasi
-
experimental or predictive designs


Focus
-

mostly older adults in home
care, public health,
community based clinics or nursing centers,
hospital,
and transitional care

Search Criteria

Searched MEDLINE
and CINAHL for
“Omaha System” 2005


2012; Omaha System website references

Inclusion criteria:


Research


Peer reviewed journals/ papers in conference proceedings


English

Excluded criteria:


Abstracts only, posters, quality improvement, news items,
websites, dissertations, student class projects (even
though they had IRB approval)


Omaha System mentioned only, not a major contribution

Literature Search Results


Number articles found


132


Number Omaha System studies
-

44


24
-

Practice


17
-

Advance Classification/ use/ interoperability


Mapping terminologies


NLP


compare text with SNL use of “other”


Bibliometrics



diffusion of SNL


Compare to other instruments / EBP guidelines i.e. OASIS, ICSI


3


Both practice and classification/ use/ interoperability


3
-

Unable to retrieve for this presentation


This presentation represents a subset of all possible research

Populations


Neighborhood


population health


Low income urban populations


MCH
-

prenatal / post
-
partum


Chronic illness (i.e. CHF, COPD, DM, other)


Elderly


Caregivers of children with fetal alcohol spectrum
disorder


Settings


Nursing centers


Public health


Home health
care


Outpatient rehabilitation


Ambulatory
care


Public forums


Transition from hospital to home

Research Methods


Descriptive


Content analysis


Mixed method


Interviews of practitioners/ secondary analysis of data


Content analysis of records, combined with structured
instruments



Quasi
-
experimental


Randomized trials


Data mining


KDD

Research Issue


Content Analysis


Brooten

et al (2007) conducted randomized control trial to
looking at the effect of ANPs


Content analysis using the Omaha System to more specifically
understand problems and interventions performed in caring for
women with high risk pregnancies


Useful for describing nursing problems and interventions


Provided evidence of what APNs did that mattered


Caley

et al (2009) analyzed transcripts of public forums to
identify needs of caregivers of children with
FASD


Used the Omaha System S&S
-

Problems


Identify nursing needs sensitive to nursing interventions not
found using
emergent coding and key word analysis





Omaha System Problems/ PRSO


Dansky

et al (2008)
evaluated
effectiveness of telehealth for
heart failure
patients

in a randomized
field study


Used the S&S of problems with the PRSO to measure symptoms
for Diet
(sodium and fluid intake), medication effectiveness, and
physical
activity


Telehome

care resulted in fewer symptoms compared with
controls, but NS


Finkelstein et al (2006) evaluated the effectiveness of
telehealth in a 3
-
group RCT


Coping
skills, activities of daily living (ADLs),
diet, medication,
circulation
(
for CHF subjects) and respiratory
(
for COPD subjects
)


Nurses used EHR to chart, subset of data used for study


Only significant difference was ADLs improved and lower costs



Comparison with Standardized
Instruments


Yu
&
Lang
(2008)


two
-
group comparative design of
outpatient rehabilitation problems, interventions, and outcomes
between clients with and without cognitive
impairment


CARE program


University of Pennsylvania


201clients, Interprofessional rehabilitation care


Traditional research instruments, second study used EHR data


Similar outcomes


comparing FIMS with Omaha System NMS
and PRSO


Different patients if using MMSE and OS Cognitive problem


measure different S&S


Recommendation is to compare trusted research instruments
with SNL


Definitions, terms





EHR/ Information Systems


Primary or secondary use of data sets for research as a bi
-
product of
previous research or clinical care


Can be more cost
-
effective data collection for research


Lu & Lin (2007)


secondary analysis of IS data, 422 elderly with DM


688 problems, 3,189 interventions


Significant decrease in blood glucose


Described problems/ interventions, but didn’t relate which influenced
outcome


Hong and
Lundeen

(2009)


evaluated client characteristics,
problems, and
interventions in a community nursing center


3,963 clients

with 9,839 encounters


9,836
nursing
interventions


Challenge is to go beyond describing care



20

Knowledge Discovery

Fayyad, U., Piatetsky
-
Shapiro, G., & Smyth, P. (1996). From data mining to knowledge discovery in databases.
AI
Magazine
, pp. 37


54.
http://www.kdnuggets.com/gpspubs/aimag
-
kdd
-
overview
-
1996
-
Fayyad.pdf
. P. 41

Rules for CDS

2,065 episodes of care


Westra
, Dey et al (2011)

Rules for CDS

2,065 episodes of care


Westra
, Dey et al (2011)

Rules for CDS

2,065 episodes of care


Westra
, Dey et al (2011)

Generating New Questions

Monsen, K., Westra, B.L., Yu, F., Ramadoss, V.K. & Kerr, M.J. (2009).
Data Management for Intervention Effectiveness
Research: Comparing Deductive and Inductive Approaches, Research in Nursing and Health, 32(6) 647
-
656
.

Complexity of
Data


KDD

Clustering
Interventions

Comparative Effectiveness Research


Mixed methods


data mining and traditional statistics


Four intervention data management approaches




Frail
vs

Non
-
Frail elderly


Omaha System Action Category


Theoretical groups


Clinical expert consensus groups (similar to CCS by AHRQ)


Data
-
driven intervention management groups


Data driven approach best fit


weak evidence (AUC .544 to
.627 for frail elderly, .526
-

.603 for non
-
frail elderly)


There were differences in interventions for frail and non
-
frail
elderly.


Different approaches may influence new knowledge

Monsen, K. A., Westra, B. L., Oancea, S. C., Yu, F., & Kerr, M. J. (2011). Linking home care interventions and
hospitalization outcomes for frail and non
-
frail elderly patients.

Research in Nursing & Health, 34
(2), 160
-
168.

Looking for Patterns:

Do PHNs Tailor Interventions?

Monsen, K.A. (2012, Publication in process

PHN Signature Styles?

Monsen, K.A. (2012, Publication in process

Standardizing Processes

EBP Guidelines


Monsen, Neely et al (2012)


demonstrated the feasibility of
encoding existing guidelines using the Omaha system


Improve interoperability, retaining nurse friendly terms


Institute for Clinical Improvement (ICSI) guideline for
depression


Intervention

Problem

Category

Target

Care Description

Asthma EBP guideline

Monsen et al (2011)

Classification, Effective Use,
Other Uses


Mapping to terminology/ instruments


NLP to analyze “other” textual data to determine if OS is
used correctly


Feasibility of integrating data across agencies & vendors


Effective use of terminology


NLP studies


Methods of data reduction into meaningful patterns


EHR issues


consistency in documentation, missing data


Time and motion studies to understand activities nurses
perform and the amount of time required


Categorize nurse management interventions


staff and
groups are considered as “client”


Overall Summary of Findings


Omaha System useful to describe nurse
-
sensitive problems in
multiple populations


Beginning evidence about the relationship of nurse
-
sensitive
problems, nursing interventions, and a variety of outcomes


Omaha System is useful for research in a variety of
community
-
based settings, populations


Many studies are still descriptive, though an increasing number
are correlational, quasi
-
experimental, and RCT


Use of large complex data sets allows us to see new patterns
to discover what nurses do that matters

Summary from Methods


Interoperability of Omaha System data


Technical interoperability


EHRs/ Agencies


Semantic interoperability


Processes interoperability


Reuse of data is invaluable for discovering knowledge in
data bases from complex data


UMN & KU: CTSA


nursing data is part of the clinical
data warehouse in process

cwd 2012

U of Minnesota

AHC Information Exchange (AHC IE)

Research Recommendations


Use standardize processes as well as standardized data


Increase use of NLP to semi
-
automate content analysis
of textual data


Expand use of data mining for knowledge discovery in
databases


practice
-
based evidence


Expand coding of EBP guidelines, embed into EHRs and
evaluate effectiveness

36


Thank you, for further information:

Bonnie
L.
Westra, PhD, RN
, FAAN, FACMI

Ass
ociate
Professor
/
Co
-
Director
Center for Nursing Informatics








University of Minnesota, School of Nursing

W
-

612
-
625
-
4470

westr006@umn.edu