The American Nurses Association is off to a slow start in influencing clinical information systems, but time and the forces of change may be on its side.
The association, through its Nursing Information and Data Set Evaluation Center, is trying to ensure that hospital information systems record nurses' work and contributions to patient care and clinical costs.
In the process, the ANA seeks recognition that nursing affects the costs of care and patient outcomes to a significant and underestimated degree.
The year-old evaluation center, known by the acronym NIDSEC, was established to determine whether healthcare software systems are serving the movement toward clinical reporting standards in nursing.
The center recently certified the first software system to meet ANA standards. That package was developed by Atlanta-based HBO & Co.
No other vendors have subjected their products to ANA scrutiny, but it's just a matter of time, says Connie Delaney, chairwoman of the ANA's NIDSEC committee. "The vendors have been requesting these sorts of standards for years," says Delaney, an associate professor at the University of Iowa College of Nursing. "It takes them some time to accommodate the standards to the level that they're confident in applying for the recognition."
As managed care changes business priorities, advocates of the evaluation initiative believe that market pressures are pushing vendors and providers toward better nursing data.
In addition, the Joint Commission on Accreditation of Healthcare Organizations is developing a position whereby the adoption of such clinical systems might be a condition of accreditation.
Data blanks. The nursing standards movement seeks to plug gaps in a documentation process that hasn't kept pace with the increasing impact of caregivers, says Carol Bickford, a senior policy fellow in the ANA's Department of Nursing Practice.
The industry's longstanding focus on physician diagnosis and procedure codes -- adopted to capture billable charges in a fee-for-service world -- ignores many activities involved in episodes of care, Bickford says.
Because providers' success depends more on managing costs than running up bills, a thorough understanding of what's done for patients in hospitals and other settings can help explain costs and outcomes more fully.
For example, a patient's response to treatment or a nursing intervention can help or hinder an outcome. But such variables aren't routinely captured, because there is no standard framework to convert nurses' observations and actions into retrievable sets of data, Bickford says.
During the past decade, government-financed research has produced several systems to describe and standardize nursing care (See chart).
However, as provider organizations seek to practice the nursing documentation protocols, they're hampered by information systems that can't support the new data-reporting processes, she says.
Minimum requirements. The idea for nursing documentation standards took root in the 1980s, before the grip of managed care but after clinicians began realizing that increasing patient acuity was creating new demands for information.
The first efforts focused on a minimum data set of patient characteristics that described specific problems to caregivers and helped providers prepare for the required care, says Roy Simpson, a registered nurse who has been involved in the ANA push since 1980 and is vice president of nursing affairs at HBO & Co.
Diagnosis codes go only so far, says Simpson. For example, a fractured femur calls for a certain nursing protocol, but incontinence can complicate care and prolong recovery time.
Incontinence is a nursing concern that isn't picked up in codes. "If you're a nurse and you're going to take care of a patient with a fractured femur, you better know that they're incontinent or you've got a big problem on your hands," Simpson says.
The problem calls for a higher level of nursing care, which affects staffing schedules, lengths of stay and costs. The standard stay for patients with a fractured femur is 4.6 days, but about 40% of femur fractures are accompanied by incontinence and an extra two days in the hospital, he says. If that fact is not reflected in budgets and managed-care contracts, big losses may result, Simpson says.
Another factor in poor outcomes and higher costs is the quality of education provided to patients about their condition and their post-hospital regimen. Nurses are principally charged with that education, but a hospital that skimps on it may pay later.
Patients who do what they're supposed to do after leaving the hospital can reduce relapses and other complications. For example, Simpson says, 60% of patients who returned to an emergency room within 48 hours of treatment for congestive heart failure hadn't taken their diuretic medicine after discharge.
With a nursing-oriented information process to track such factors as immobility, incontinence and patient education, healthcare facilities "can begin to look at all the variables that affect patient care," she says.
Technical needs. The National Institute of Nursing Research, part of the National Institutes of Health, has provided $40 million in grants toward the effort. A half-dozen initiatives have produced systems to classify diagnoses, interventions and outcomes, and to structure them into codes that can be compiled and analyzed, Simpson says.
But nursing still needed a computerized framework to implement the standardized systems and allow caregivers to use the information throughout the continuum of care, Bickford says.
With standards of nursing activity in good shape, the ANA turned its attention to fostering the standards needed to automate the new and more complex documentation systems, she says.
The ANA center charges a $20,000 fee per evaluation and has been open for business since December 1997. HBO & Co.'s Pathways Care Manager met standards for completeness, accuracy and appropriateness of four dimensions of nursing data sets, including:
* Standard terms defined in a reporting system.
* Clinical content, or the way terms are logically associated with one another.
* Clinical data repository, or the way data are stored and made accessible.
* General system characteristics, such as performance and attention to patient confidentiality.
Bickford says at least one ANA-recognized nursing classification system must be used to represent the nursing component of care.
The center's guidelines state: "The best clinical system includes structured terminology to record each portion of the nursing process of assessment, diagnosis, setting expected outcomes or goals, planning and completing interventions, and completing evaluation of actual outcomes."
Simpson says appropriate software must have the functional depth and range to handle documentation, enabling nurses to record data that can be shared and compared throughout a delivery system and plugged into the management of outcomes and quality.
Software functions are similar to Microsoft Word's role when a user composes a letter, he says: The program doesn't provide the letter but does provide the form, change the typefaces, save the document for import into other programs and perform other word-processing tasks that support letter-writing.
Bandwagon awaits. About 10 publicly held information systems companies have paid $100 for the packet detailing the basis for product evaluation, but the ANA center is still waiting for its second taker.
Meanwhile, Simpson says, the three-year certification from the ANA will come in handy as HBO & Co. pitches its wares to prospects. Before the company received ANA approval, customers were asking if the Pathways Care Manager program was "NIDSEC-ready," he says.
A year ago, 5% to 10% of prospective buyers of the HBO & Co. program specifically requested that information. Now that number is 60% to 70%, Simpson maintains.
Part of the demand stems from managed-care concerns, but another consideration is the JCAHO's call for the systematic tracking and management of patients across a healthcare continuum, she says. Emerging standards for managing information as part of accreditation specify "a coded data structure for nursing," he says.
In the five years the JCAHO has enforced information management standards, the Oakbrook Terrace, Ill.-based accreditation agency has made it clear that it wasn't requiring computerization, says Carole Patterson, deputy director of the department of standards. But in the 2000 and 2001 accreditation manuals being developed, the JCAHO is considering requiring computer systems that document clinical outcomes, she says.