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Objectives. To evaluate the feasibility of implementing a statewide children with special health care needs (CSHCN) program evaluation, case management, and surveillance system using a standardized instrument and protocol that operationalized the United States Health and Human Services CSHCN National Performance Measures. Methods. Public health nurses in local public health agencies in Washington State jointly developed and implemented the standardized system. The instrument was the Omaha System. Descriptive statistics were used for the analysis of standardized data. Results. From the sample of CSHCN visit reports (n=127), 314 problems and 853 interventions were documented. The most common problem identified was growth and development followed by health care supervision, communication with community resources, caretaking/parenting, income, neglect, and abuse. The most common intervention category was surveillance (60%), followed by case management (24%) and teaching, guidance, and counseling (16%). On average, there were 2.7 interventions per problem and 6.7 interventions per visit. Conclusions. This study demonstrates the feasibility of an approach for statewide CSHCN program evaluation, case management, and surveillance system. Knowledge, behavior, and status ratings suggest that there are critical unmet needs in the Washington State CSHCN population for six major problems.

Objective To examine the associations between social and behavioral determinants of health (SBDH), health disparities, and the outcomes of women who received public health nurse home visits for pregnancy and parenting support. Design Observational exploratory data analysis and comparative outcome evaluation. Setting An extant dataset from women served in a Midwestern U.S. state, including demographics and Omaha System problems, signs/symptoms, interventions, and outcome assessments. Participants Women ( N = 4,263) with an average age of 23.6 years ( SD = 6.1); 21.4% were married, and 39.1% were White. Methods An evaluation dataset was constructed that included all women of childbearing age, their demographics, and outcome assessments. A summative SBDH Index based on Institute of Medicine-recommended instruments was computed based on sign/symptom data. Visualizations were developed using Microsoft Excel, and outcome significance statistics were computed using SPSS version 22 and SAS version 9.4. Results Outcome evaluation showed positive, significant changes from baseline after public health nurse intervention. Visualization showed variable concentrations of problem-specific signs/symptoms by SBDH Index subgroups. There were between-group differences in overall outcome attainment across SBDH Index subgroups. Compared with White women, minority women had greater improvement; however, despite these gains overall minority final ratings were lower. Conclusion An informatics approach showed that SBDH are important factors for understanding a comprehensive and holistic view of health and health care outcomes. There is potential to use large datasets to further explore intervention effectiveness and progress toward health equity related to SBDH.

This poster describes a method to prepare noise and health data from wearable technology for standardized representation in the electronic personal health record thus enabling individuals to identify noise-related health risks. Using a case study approach, the authors demonstrate transformation of data to the Omaha System standardized terminology in order to depict the data graphically in a personal health record.

This study aims to discover groups (clusters) of patient who share whole-person characteristics. An unsupervised clustering analysis using a hierarchical agglomerative approach was applied to identify meaningful groups of patient characteristics. Results showed that is possible to identify clusters that have similar patient characteristics, and that these characteristics may be associated with survival.

Capturing strengths at the community level offers an emergent perspective to a strength-based approach for population health. The Omaha System standardized terminology has been found feasible to describe individual strengths in patient care planning. This study depicts results of using the Omaha System to capture strengths at the community level. Descriptive statistics and visualization were used to examine patterns of strengths and signs/symptoms by Omaha System Problem concept based on the secondary data analysis from 118 student-generated community assessments. Results suggest that it is feasible to use the Omaha System as a method classifying strengths and problems at the community level. The relationship between strengths and signs/symptoms is consistent with the pattern observed at the individual-level. Utilizing a strength-based model may provide robust information about community strengths leading to new approaches to population health management in support of community wellbeing.

Background: A whole-person representation captures not only patient problems but also patient strengths. To better understand and inform practice of person-centered care and documentation using a whole-person representation, a critical review of literature was conducted of the current state of patient problems and strengths documentation in electronic health records. Methods: The informatics model of Data, Information, Knowledge and Wisdom is employed to develop this critical review. Two scientific databases were used to conduct a systematic search: CINAHL and Ovid Medline with the following search terms: strength*, problem*, whole person, wellbeing or well-being, electronic health record*, personal health record*, EHR*, and PHR*. 602 articles were returned. All articles were screened through review of titles, abstracts, or full texts. 24 articles were selected for this review. Results: Four themes have emerged from this critical review. They are individual or cross-institutional use of problem-oriented EHRs, extension of problem-based EHRs with other integration, patient-centered integration of the problem-oriented EHR build, and construction of a whole-person representation to include strengths in the EHR documentation. The vast majority of articles focus on problem-based diagnoses and practices. Early reports of strengths documentation were found using a standardized interface terminology and ontology, the Omaha System. Results of two studies demonstrated the feasibility of using the Omaha System for whole-person documentation to capture perception of both problems and strengths. Conclusion: Clinical information in EHRs is typically structured by problem-based diagnoses; however, there is emerging documentation of formalized strengths attributes using the Omaha System, which may promote a holistic approach to clinical practice and documentation using a person-centered, strength-based ontology.

Evidence-based clinical guidelines are being developed to bridge the gap between research and practice with the goals of improving health care quality and population health. However, disseminating, implementing, and ensuring ongoing use of clinical guidelines in practice settings is challenging. The purpose of this study was to demonstrate the feasibility of encoding evidence-based clinical guidelines using the Omaha System. Clinical documentation with Omaha System-encoded guidelines generates individualized, meaningful data suitable for program evaluation and health care quality research. The use of encoded guidelines within the electronic health record has potential to reinforce use of guidelines, and thus improve health care quality and population health. Research using Omaha System data generated by clinicians has potential to discover new knowledge related to guideline use and effectiveness.

An invited group of national public health nursing (PHN) scholars, practitioners, policymakers, and other stakeholders met in October 2010 identifying a critical need for a national PHN data infrastructure to support PHN research. This article summarizes the strengths, limitations, and gaps specific to PHN data and proposes a research agenda for development of a PHN data infrastructure. Future implications are suggested, such as issues related to the development of the proposed PHN data infrastructure and future research possibilities enabled by the infrastructure. Such a data infrastructure has potential to improve accountability and measurement, to demonstrate the value of PHN services, and to improve population health.

SummaryBackground: There is a critical need to reduce hospitalizations for Medicare patients and electronic health record (EHR) home care data provide new opportunities to evaluate risk of hospitalization for patients.Objectives: The objectives of this study were to 1) develop a measure to predict risk of hospitalization among home care patients, the Hospitalization Risk Score (HRS), and 2) compare it with an existing severity of illness measure, the Charlson Index of Comorbidity (CIC).Methods: A convenience sample of clinical data from 14 home care agencies’ EHRs, representing 1,643 home care patient episodes was used for the study. The development of the HRS was based on review of the literature, and expert panel evaluation to construct the HRS. Descriptive statistics and generalized linear models were used for comparative analysis; areas under curve (AUC) values were compared for receiver operating curves (ROC), and cut points predicting hospitalization were evaluated.Results: The HRS for this sample ranged from 0 to 5.6, with a median of 1.25. The CIC for this sample ranged from 0 to 9 and with a median of 0. Nearly three fourths of the sample was hospitalized at an HRS of 2, and a CIC of 1. AUC values for ROC were 0.63 for HRS and 0.59 for the CIC. The ROC curves were significantly different (t = -7.59, p Conclusions: This preliminary study demonstrates the potential value of the HRS using Omaha System EHR data. There was a statistically significant difference for predicting hospitalization of home care patients with the HRS versus the CIC; however the AUC values for both were low. Continued research is needed to further refine the HRS, determine whether it is more sensitive for particular subgroups of patients, and combine it with additional risk factors in understanding rehospitalization.Citation: Monsen KA, Swanberg HL, Oancea SC, Westra BL. Exploring the value of clinical data standards to predict hospitalization of home care patients. Appl Clin Inf 2012; 3: 419–436http://dx.doi.org/10.4338/ACI-2012-05-RA-0016

SummaryBackground: EHR clinical document synthesis by clinicians may be time-consuming and error-prone due to the complex organization of narratives, excessive redundancy within documents, and, at times, inadvertent proliferation of data inconsistencies. Development of EHR systems that are easily adaptable to the user’s work processes requires research into visualization techniques that can optimize information synthesis at the point of care.Objective: To evaluate the effect of a prototype visualization tool for clinically relevant new information on clinicians’ synthesis of EHR clinical documents and to understand how the tool may support future designs of clinical document user interfaces.Methods: A mixed methods approach to analyze the impact of the visualization tool was used with a sample of eight medical interns as they synthesized EHR clinical documents to accomplish a set of four pre-formed clinical scenarios using a think-aloud protocol.Results: Differences in the missing (unretrieved) patient information (2.3±1.2 [with the visualization tool] vs. 6.8±1.2 [without the visualization tool], p = 0.08) and accurate inferences (1.3±0.3 vs 2.3±0.3, p = 0.09) were not statistically significant but suggest some improvement with the new information visualization tool. Despite the non-significant difference in total times to task completion (43±4 mins vs 36±4 mins, p = 0.35) we observed shorter times for two scenarios with the visualization tool, suggesting that the time-saving benefits may be more evident with certain clinical processes. Other observed effects of the tool include more intuitive navigation between patient details and increased efforts towards methodical synthesis of clinical documents.Conclusion: Our study provides some evidence that new information visualization in clinical notes may positively influence synthesis of patient information from EHR clinical documents. Our findings provide groundwork towards a more effective display of EHR clinical documents using advanced visualization applications.Citation: Farri O, Rahman A, Monsen KA, Zhang R, Pakhomov SV, Pieckiewicz DS, Speedie SM, Melton GB. Impact of a prototype visualization tool for new information in EHR clinical documents. Appl Clin Inf 2012; 3: 404–418http://dx.doi.org/10.4338/ACI-2012-05-RA-0017

Objectives: Benchmark client outcomes across public health nursing (PHN) agencies using Omaha System knowledge, behavior, and status ratings as benchmarking metrics. Design and Sample: A descriptive, comparative study of benchmark attainment for a retrospective cohort of PHN clients (low-income, high-risk parents, primarily mothers) from 6 counties. Measures: Omaha System Problem Rating Scale for Outcomes data for selected problems. Benchmark measures were defined as a rating of 4 on a scale from 1 (lowest) to 5 (highest). Intervention: Family home visiting services to low-income, high-risk parents. Results: The highest percentage of benchmark attainment was for the Postpartum problem (knowledge, 76.2%; behavior, 94.0%; status, 96.6%), and the lowest was for the Interpersonal relationship problem (knowledge, 21.7%; behavior, 69.0%; status, 40.7%). All counties showed significant increases in client knowledge benchmark attainment, and 4 of 6 counties showed significant increases from baseline in behavior and status benchmark attainment. Significant differences were found between counties in client characteristics and benchmark attainment for knowledge, behavior, and status outcomes. Conclusions: There were consistent patterns in benchmark attainment and outcome improvement across counties and family home visiting studies. Benchmarking appears to be useful for comparison of population health status and home visiting program outcomes.

Background The purpose of this study was to evaluate outcomes of public health nurse home visiting for mothers with intellectual disabilities (ID) and a comparison group. Methods The study was a secondary analysis of existing de-identified family home visiting data. It used a two-group comparative, 1:3 match design. Sixty-eight clients were in the study (n = 17 for mothers with ID and n = 51 for mothers without ID). Client characteristics and problem prevalence were compared using standard descriptive and inferential statistics. Mixed model methods were used for the analysis of outcomes, accounting for baseline scores, time of services and matched cases. Results Mothers with and without ID showed statistically significant improvement following family home visiting services. For both groups, discharge scores were consistently higher than the corresponding admission scores, with a mean increase of 0.37 (range = 0.05–0.90). Mothers without ID attained higher outcomes than mothers with ID. Seven of 21 outcomes significantly improved for mothers with ID, and 10 of 21 for the comparison group. The percentage of mothers with ID attaining the benchmark of 4 ranged from 13.3% to 90.4% and for the comparison group ranged from 30% to 95.7%. Public health nurses addressed 15 environmental, psychosocial, physiological and behavioural problems for both groups. Conclusion Family home visiting appears to be effective in assisting parents with ID to have improved outcomes in many domains. These results provide an opportunity for service providers, home visiting nurses and public health agencies to understand the unique needs of mothers with ID.

Structured clinical data generated using standardized terminologies such as the Omaha System are available for evaluating healthcare quality and patient outcomes. New intervention management grouping approaches are needed to deal with large, complex clinical intervention data sets. We evaluated 56 intervention groups derived using four data management approaches with a data set of 165,700 interventions from 14 home care agencies to determine which approaches and interventions predicted hospitalizations among frail (n = 386) and non-frail (n = 1,364) elders. Hospitalization predictors differed for frail and non-frail elders. Low frequencies in some intervention groups were positively associated with hospitalization outcomes, suggesting that there may be a mismatch between the level of care that is needed and the level of care that is provided. © 2011 Wiley Periodicals, Inc. Res Nurs Health

Objectives: To use structured clinical data from public health nurse (PHN) documentation to describe client risk, to describe family home visiting interventions, including tailoring, and to assess the associations between client risk and intervention tailoring. Design and Sample: Retrospective cohort design. A cohort of 486 family home visiting clients who received at least 3 visits from PHNs in a local Midwest public health agency (2000–2005). Measures: Omaha System variables documenting assessments, interventions, and outcomes. A risk index was created to identify low- and high-risk clients. Descriptive and inferential methods were used to describe interventions, and to assess intervention tailoring between groups. Intervention: Routine PHN family home visiting practice. Results: The risk index meaningfully discriminated between groups. PHNs provided more visits and interventions to clients in the high-risk group, with variations in problem, category, and target by group, demonstrating that PHNs tailored interventions to address specific client needs. Conclusions: Standardized terminologies and structured clinical data are useful tools to support PHN practice, and may be useful to advance health care quality research, program evaluation, policy development, and population health outcomes.

Meaningful use has become ubiquitous in the vocabulary of health information technology. It suggests that better healthcare does not result from the adoption of technology and electronic health records, but by increasing interoperability and informing clinical decisions at the point of care. Although the initial application of meaningful use was limited to eligible professionals and hospitals, it incorporates complex processes and workflow that involve all nurses, other healthcare practitioners, and settings. The healthcare community will become more integrated, and interdisciplinary practitioners will provide enhanced patient-centered care if electronic health records adopt the priorities of meaningful use. Standardized terminologies are a necessary component of such electronic health records. The Omaha System is an exemplar of a standardized terminology that enables meaningful use of clinical data to support and improve patient-centered clinical practice, education, and research. It is user-friendly, generates data that can be shared with patients and their families, and enables healthcare providers to analyze and exchange patient-centered coded data. Use of the Omaha System is increasing steadily in diverse practice, education, and research settings nationally and internationally.

Summary Background: Public health nurse (PHN) home visiting programs have been widely employed to improve life course trajectories for high risk mothers. Home visiting programs are often lengthy, during which PHNs simultaneously address multiple problems using diverse interventions over several client encounters. To manage PHN caseloads it is critical to understand the trajectory of client improvement and the optimal duration or services. PHN documentation data enable intervention trajectory research for specific client problems. A new metric called problem stabilization is proposed for evaluating interim improvement during PHN home visiting. Problem stabilization is an intervention pattern for a client problem that is characterized by co-occurring actions (i.e. teaching, guidance, and counseling; treatments and procedures; case management; and/or surveillance) during a client encounter; followed by surveillance actions only for that problem during a subsequent client encounter. The purpose of the study was to investigate problem stabilization during home visiting services for high risk mothers. Methods: A retrospective cohort was created using family home visiting intervention documentation data from a local Midwest public health agency over a six year period (2000–2005). The data set consisted of Omaha System interventions for 720 high risk mothers. Analysis was conducted using descriptive statistics and Kaplan Meier curves. Results: On average 30.1% of the time, client problems stabilized before discharge. Stabilization patterns differed by problem. Time to stabilization was longest for Caretaking/parenting and Ante-partum/postpartum problems, and shortest for Residence and Mental health problems. Conclusions: Problem stabilization, a proposed intermediate outcome of PHN home visiting care, appears to be meaningful in describing client response to PHN intervention. This metric is an example of meaningful use of structured clinical electronic health record data for program evaluation and clinical decision support.

SummaryInterface terminologies used in electronic health records must be re-evaluated and revised to reflect current health care practice and knowledge. To enable future revisions of the Omaha System Intervention Scheme, investigators evaluated formal semantic structure of target terms and concept duplication of problem and target terms. Using linguistic principles and qualitative analysis, five themes were found. A multidimensional formal semantic structure for the intervention target term was proposed. Concept duplication was examined for 16 problem-target matches. Clinical data enabled assessment of the validity of a proposed formal semantic structure and concept duplication. Recommendations are suggested for future development of the Omaha System Intervention Scheme.

Many East African refugee women have experienced torture and trauma while fleeing from their home countries. Many also experience high rates of isolation, depression, and symptoms of posttraumatic stress disorder after resettlement. Effective methods are needed for improving the mental well-being of this population. This pilot study (N = 19) tested the feasibility, accessibility, and acceptability of a strengths-based, community-delivered intervention with Somali and Ethiopian women refugees. Feasibility was established through recruitment, retention, participation, and participant response. Accessibility was established through providing meals, transportation, and child-care assistance. Acceptability was established through evaluating translated materials, cultural congruence, and perceived relevance. Results support testing in a full-scale controlled study.

Family home visiting is a widely accepted strategy used with disadvantaged families to mitigate the effects of poverty. However, gaps persist in knowledge of effective intervention approaches for home visiting relative to specific client risks such as parenting and psychosocial problems. The purpose of this study was to inductively create clusters from electronic health records of 484 public health nursing clients, using client characteristics and intervention data. Four clinically relevant client clusters were generated using Mixed Membership Naïve Bayes methods. Fourteen distinct intervention clusters were generated using KMETIS, a graph partitioning method. The content of the intervention clusters illustrates the complexity of public health nursing practice. This study leverages current nursing documentation technology capacity to advance nursing knowledge. Future research is needed to explore relationships between client and intervention clusters and their associations with client outcomes, with the end goals of improving home visiting practice and client outcomes.

To use aggregated data from health informatics systems to identify needs of maternal and child health (MCH) clients served by county public health agencies and to demonstrate outcomes of services provided. Participating agencies developed and implemented a formal standardized classification data comparison process using structured Omaha System data. An exploratory descriptive analysis of the data was performed. Summary reports of aggregated and analyzed data from records of clients served and discharged in 2005 were compared. Client problems and outcomes were found to be similar across agencies, with behavioral, psychosocial, environmental and physiological problems identified and addressed. Differential improvement was noted by problem, outcome measure, and agency; and areas for enhancing intervention strategies were prioritized. Problems with greatest improvement across agencies were Antepartum/postpartum and Family planning, and least improvement across agencies were Neglect and Substance use. Findings demonstrated that public health nurses address many serious health-related problems with low-income high-risk MCH clients. MCH client needs were found to be similar across agencies. Public health nurse home visiting services addressed important health issues with MCH clients, and statistically significant improvement in client health problems occurred consistently across agencies. The data comparison processes developed in this project were useful for MCH programs, and may be applicable to other program areas using structured client data for evaluation purposes. Using informatics tools and data facilitated needs assessment, program evaluation, and outcomes management processes for the agencies, and will continue to play an integral role in directing practice and improving client outcomes.

In the digital age, it is critical for both healthcare professionals and consumers to electronically express, receive, and processimportant health information. This is especially true for populations with language barriers and low literacy. Visual literacy andhealth literacy enable optimal health communication and wellbeing. A standardized interface terminology is a linguistic tool thatcan be used to convey health information at the human-computer interface. The Omaha System has been evaluated and foundto be a promising standard for use as a simple, standardized terminology that may promote health literacy and communicationbetween healthcare professionals and consumers. However, a method for visually representing health concepts described by theOmaha System has not been developed. The purpose of this study was to develop a complete set of 42 icons that convey themeaning of each of the 42 Omaha System problem concepts as defined by Martin (2005). Design thinking, universal designmethods, and informal survey evaluations were used to determine appropriate imagery for the icons. Data-based revisions wereincorporated after each of three informal survey evaluations. The resulting set of 42 icons for Omaha System problem concepts isavailable in the public domain. Future plans are to conduct extensive global evaluation of concept validity and usefulness of theicons across literacy levels.

Objectives The purpose of this study was to determine the feasibility of using a standardized language, the Omaha System, to capture community-level observations to facilitate population assessment and electronic information exchange. The objectives were: (1) to evaluate the feasibility of using the Omaha System at the community level to reflect community observations and (2) to describe preliminary results of community observations across international settings. Design and Sample Descriptive. A dataset of 284 windshield surveys (community observations) completed by nursing students in five countries: Mexico, New Zealand, Norway, Turkey, and the United States. Measures The Omaha System Problem Classification Scheme provided standardized terms for assessment of communities in an online checklist of 11 problems and their respective signs/symptoms. Results Feasibility was demonstrated: students were able to describe community observations using standardized terminology from the Omaha System. Preliminary results describe variations in community signs and symptoms by location. Conclusions The Omaha System appears to be a useful tool for community-level observations and a promising strategy for electronic exchange of population health assessments.

Purpose Although discharge planning (DP) is recognized as a critical component of hospital care, national initiatives have focused on older adults, with limited focus on pediatric patients. We aimed to describe patient problems and targeted interventions as documented by social workers or DP nurses providing specialized DP services in a children's hospital. Methods Text from 67 clinical notes for 28 patients was mapped to a standardized terminology (Omaha System). Data were deductively analyzed. Results A total of 517 phrases were mapped. Eleven of the 42 Omaha System problems were identified. The most frequent problem was health care supervision (297/517; 57.4%). Three Omaha System intervention categories were used (teaching, guidance, and counseling; case management; and surveillance). Intervention targets are varied by role. Conclusion The findings provide a rich description of the nature of DP for complex pediatric patients and increase our understanding of the work of DP staff and the influence of the DP practice model.

Informatics is a new science within healthcare and anesthesia that leverages computer technology to improve patient safety, the quality of care provided, and workload efficiency. In clinical anesthesia practice, appropriate application of informatics promotes data standardization and integrity, and supports clinical decision-making. This article describes current issues in anesthesia information management to support the critical need for Certified Registered Nurse Anesthetists (CRNAs) to influence functionality, adoption, and use of an anesthesia information management system. The use of informatics tools and concepts should enable CRNAs to enhance their bedside vigilance, align their practice with evidence-based clinical guidelines, and provide cost-effective care for patients and healthcare systems.

A promising strategy for enhancing care and self-management of chronic illness is an integrative, whole-person approach that recognizes and values well-being. Assessment tools are needed that will enable health care professionals to perceive patients as whole persons, with strengths as well as problems. The purpose of this study was to examine the feasibility of using a standardized terminology (theOmaha System) to describe strengths of older adults with chronic illness. The Omaha System assessment currently consists of identifying signs/symptoms for 42 health concepts. Researchers mapped self-reported strengths phrases to Omaha System concepts using existing narratives of 32 older adults with 12–15 comorbid conditions. Results demonstrated the feasibility of describing strengths of patients with chronic illness. Exploratory analysis showed that there were 0–9 strengths per patient, with unique strengths profiles for 30 of 32 patients. Given that older adults with multiple chronic illnesses also have strengths that can be classified and quantified using the Omaha System, there is potential to use the Omaha System as a whole-person assessment tool that enables perception of both problems and strengths. Further research is needed to enhance the Omaha System to formally represent strengths-based as well as a problem-focused perspectives.

Automation of nursing documentation in client records is one of today's formidable challenges in healthcare settings. Some stakeholders view standardized nursing language as a fundamental component of an automated record, with the end goal of generating valid, reliable data on nursing services and client outcomes. However, few successful applications of standardized nursing language for practice standards and data generation exist in the literature. A joint practice-and-data quality project based on standardized nursing language in an automated platform was undertaken by four local public health departments. Outcomes of this project included articulation of standards for nursing practice and creation and implementation of a sound data quality infrastructure for nursing documentation of client assessments, service delivery information, and client outcomes.

Increased data reporting requirements, reimbursement changes, and automation capabilities provide new challenges for home health care and public health agencies today. These factors have become the impetus for computerization of practitioner documentation. Standardized documentation systems such as the Omaha System allow agencies to describe client needs, service delivery, and related client outcomes and to generate powerful data when used consistently and reliably in practice settings. This article offers practical suggestions for assuring data quality as well as simple, effective analysis and reporting strategies. Several figures depicting Omaha System documentation data from diverse programs are included as examples.

Pediculosis is a population-based problem that is a priority concern for many communities. Public health nurses in a county health department collaborated with epidemiologists, nursing students, and faculty to design and implement an effective population-based pediculosis management project. The focus of the project was the development of pediculosis treatment and prevention guidelines based on recognized best practices that were acceptable to both epidemiologists and practicing public health nurses. Public health nurses disseminated these guidelines to community providers and reinforced their use through consultation and educational sessions. Two critical changes occurred as a result of the project. First, community providers significantly changed their recommendations for the treatment of pediculosis after nursing intervention. Second, public health nurses increased their population-based practice skills, continued to use those skills to address pediculosis, and extended those skills to additional population-based initiatives.

Objective: To examine the associations between social and behavioral determinants of health (SBDH) and frailty among older adults using an existing Omaha System dataset collected in the community. Design: Secondary exploratory data analysis. Setting: An existing dataset of home health records from a Midwestern region, including Omaha System problems, interventions, and Knowledge (K), Behavior (B), and Status (S) outcomes. Participants: Older adults (n = 1,618) that were 63.7% female with an average age of 80.1 years (SD = 7.6). Methods: This exploratory data analysis study reused an existing Omaha System dataset to reveal hidden patterns in health outcomes of frail vs. non-frail older adults relative to SBDH. Two separate metrics were used to classify SBDH and frailty. An existing summative SBDH index was derived from measures recommended by the Institute of Medicine (IOM). A new frailty index was created based on Omaha System terms mapped to frailty criteria established by Fried and colleagues. Heat maps and line graphs were developed using Microsoft Excel and R. Patterns were discovered and related hypotheses were evaluated using paired samples t-tests and two-way ANOVA tests in R. Results: Records (n = 1,618) were divided into SBDH Group 0 with no SBDH Problems (n = 1,397) and SBDH Group 1 with one or more SBDH Problems (n = 221). Overall, there was significant improvement in KBS after home care interventions. SBDH, Frailty, and interactions between SBDH and Frailty were significantly associated with differences in KBS outcomes. Visualizations showed numerous potential patterns for further research. Discussion: SBDH Group 1 was largely defined by having the Mental health problem. Being in SBDH Group 1 was negatively associated with KBS outcomes. This aligns with the literature on the impact of mental health on overall health and wellbeing. As frailty scores increased, KBS outcomes decreased, demonstrating a possible continuum of increasing frailty as related co-morbidities accrued. This is a new perspective on frailty that should be further investigated. SBDH group, Frailty, and SBDH-Frailty interaction were all important for understanding outcomes for final K, final S, and difference in K, B, and S. For final B, SBDH group and Frailty were important. Because interaction between SBDH and Frailty was observed for most problems and outcomes, researchers who study Frailty should account for SBDH, especially mental health. SBDH problems were infrequent in the data. This has implications for our ability to understand SBDH in home care. Future research should incorporate data that include SBDH problem assessments. Conclusion: This exploratory data analysis study identified relationships between SBDH and frailty for older adults along a continuum of frailty using the Omaha System. Further research is needed to validate the findings and to evaluate the metrics with other datasets and populations.

Introduction High Risk Medication Regimen (HRMR) scores are weakly predictive of hospital readmissions for elderly home health care patients. HRMR is composed of three elements related to drug risks: polypharmacy (number of medications); Potentially Inappropriate Medications (PIM) known to be harmful to the elderly; and the Medication Regimen Complexity Index (MRCI) that weighs drugs by the complexity of their dosing and instructions. In this paper, we hypothesized that HRMR scores are more predictive for demographic subgroups of elderly patients. The study used Outcome and Assessment Information Set (OASIS) variables to identify subgroups of patients for whom the HRMR measures appeared more predictive for hospital readmissions. Methods OASIS and medication data were reused from a study of 911 patients (355 males, 556 females; mean age 78.9) from 15 Medicare-certified home health care agencies that established the relationship between HRMR and hospital readmissions. Hierarchical agglomerative clustering using the Jaccard distance measure and average-link method identified patient subgroups based on the OASIS data. Receiver operating curve (ROC) analyses evaluated the predictive strength of the HRMR variables for each subgroup. Additional False Discovery Rate (FDR) analyses assessed whether the clustered relationships were chance. Results Clustering of OASIS data for 911 patients identified six subgroups: patients with Good Functional Status ( n =382); Females with Moderate to Severe Pain ( n =354); patients with poor prognosis needing functional status assistance ( n =419); patients with Poor Functional Status ( n =287); Males with Adult Children as Caregiver ( n =198); adults living alone with spouses as primary caregiver ( n =127). ROC results relating these subgroups to HRMR risks were strongest for Males with Adult Children as Caregivers (AUC: polypharmacy, 0.73; PIM, 0.64; MRCI, 0.77). The findings for this subgroup also met the FDR analysis threshold ( Conclusions A risk of medication-related readmissions in elderly men with adult children as caregivers is consistent with research showing problems in medication adherence when seniors are supported by informal caregivers. The results from clustering analysis present a hypothesis for research on HRMR and on the relationship between adult caregivers and their fathers.

Consumer involvement in healthcare is critical to support continuity of care for consumers to manage their health while transitioning from one care setting to another. Validation of evidence-based practice (EBP) guideline by consumers is essential to achieving consumer health goals over time that is consistent with their needs and preferences. The purpose of this study was to compare an Omaha System EBP guideline for community dwelling older adults with consumer-derived evidence of their ongoing needs, resources, and strategies after home care discharge. All identified problems were relevant for all patients except for Neglect and Substance use. Ten additional problems were identified from the interviews, five of which affected at least 10% of the participants. Consumer derived evidence both validated and expanded EBP guidelines; thus further emphasizing the importance of consumer involvement in the delivery of home healthcare.

Homecare is the fastest growing healthcare sector and evidence based information systems are critically needed. Nurses provide most of the care in homecare setting, yet there is a lack of knowledge on the feasibility of applying existing methodologies to generate computer interpretable nursing guidelines for home care. This study examined the feasibility of encoding homecare nursing heart failure guideline into a computer interpretable format. First, we achieved experts’ consensus on the relevant guideline. Then, after training on the graphical tool for gradual knowledge specification (Gesher), we generated a comprehensive, hierarchical and time-oriented computer interpretable guideline using one of the guideline modeling languages (Asbru). The final guideline included 167 recommendations and experts’ evaluation confirmed the adequacy of guideline knowledge representation. Future work should expand the applicability of our methodology and tools to nursing specialties other than heart failure and develop methods for comprehensive quality evaluation of the resulting guidelines.

This chapter explores the intersection of informatics and integrative healthcare and the synergy of possibilities that are rapidly emerging. Big data, information science, and network science are new tools for advancing interprofessional healthcare knowledge and wisdom. Integrative healthcare, nursing, and all healthcare professions can leverage the benefits of informatics to improve information management; support and document care; and capture outcomes. We invite conversation, creative practice, and contribution to the evolution of our research and science that boldly represents the healthy synergy between integrative informatics and integrative health.

Buurtzorg is a nurse-led, nurse-run organization of self-managed teams that provide home care to patients in their neighborhoods. Championing humanity over bureaucracy, autonomous teams work with primary care providers, community supports, and family resources to bring patients to optimal functioning as quickly as possible. The award-winning organization grew out of a common sense approach based on principles of trust, autonomy, creativity, simplicity, and collaboration. These organizational principles translate into highly effective and efficient care, satisfied patients, and enthusiastic nurses. The model is being replicated worldwide, with teams starting in Minnesota, Sweden, Japan, and other countries.

Summary Background: The Omaha System is a standardized interface terminology that is used extensively by public health nurses in community settings to document interventions and client outcomes. Researchers using Omaha System data to analyze the effectiveness of interventions have typically calculated p-values to determine whether significant client changes occurred between admission and discharge. However, p-values are highly dependent on sample size, making it difficult to distinguish statistically significant changes from clinically meaningful changes. Effect sizes can help identify practical differences but have not yet been applied to Omaha System data. Methods: We compared p-values and effect sizes (Cohen’s d) for mean differences between admission and discharge for 13 client problems documented in the electronic health records of 1,016 young low-income parents. Client problems were documented anywhere from 6 (Health Care Supervision) to 906 (Caretaking/parenting) times. Results: On a scale from 1 to 5, the mean change needed to yield a large effect size (Cohen’s d 0.80) was approximately 0.60 (range = 0.50 – 1.03) regardless of p-value or sample size (i.e., the number of times a client problem was documented in the electronic health record). Conclusions: Researchers using the Omaha System should report effect sizes to help readers determine which differences are practical and meaningful. Such disclosures will allow for increased recognition of effective interventions.

Graphical abstractDisplay Omitted Cognitive pathways of interns' EHR note synthesis under timed and untimed conditions.Adjustments of interns' information consumption based on awareness of time constraints.Non-significant difference in errors for timed and untimed EHR note synthesis. BackgroundTime is a measurable and critical resource that affects the quality of services provided in clinical practice. There is limited insight into the effects of time restrictions on clinicians' cognitive processes with the electronic health record (EHR) in providing ambulatory care. ObjectiveTo understand the impact of time constraints on clinicians' synthesis of text-based EHR clinical notes. MethodsWe used an established clinician cognitive framework based on a think-aloud protocol. We studied interns' thought processes as they accomplished a set of four preformed ambulatory care clinical scenarios with and without time restrictions in a controlled setting. ResultsInterns most often synthesized details relevant to patients' problems and treatment, regardless of whether or not the time available for task performance was restricted. In contrast to previous findings, subsequent information commonly synthesized by clinicians related most commonly to the chronology of clinical events for the unrestricted time observations and to investigative procedures for the time-restricted sessions. There was no significant difference in the mean number of omission errors and incorrect deductions when interns synthesized the EHR clinical notes with and without time restrictions (3.5?0.5 vs. 2.3?0.5, p=0.14). ConclusionOur results suggest that the incidence of errors during clinicians' synthesis of EHR clinical notes is not increased with modest time restrictions, possibly due to effective adjustments of information processing strategies learned from the usual time-constrained nature of patient visits. Further research is required to investigate the effects of similar or more extreme time variations on cognitive processes employed with different levels of expertise, specialty, and with different care settings.

The purpose of this study was to evaluate the use of a standardized interface terminology, the Omaha System, with respect to noise-induced hearing loss (NIHL).A descriptive, correlational design was employed for this secondary analysis with the data from an ongoing hearing protection intervention study.A total of 346 firefighters were included.First, an evidence-based standardized care plan (EB-SCP) for hearing screening was developed and validated by clinical experts. Second, occupational health records were used to compute Omaha System Knowledge, Behavior, and Status outcomes. Third, research data were mapped to Omaha System rating scales. For Knowledge, the mean score was close to 'adequate' (3.7). For Behavior, the mean score was close to 'rarely appropriate' (2.2). For Status, the mean score was close to 'minimal sign/symptom' (4.4). Significant positive relationships were found between Knowledge and Behavior (Spearman's rho =.13, p =.01), and between Behavior and hearing Status (Spearman's rho =.12, p =.02).Findings support the validity of the new Knowledge, Behavior, and hearing Status. Informatics methods such as the standardized NIHL EB-SCP and outcome data sets will create opportunities for clinical decision support and data exchange across various health care settings, thus supporting population-based hearing health assessments and outcomes.

To empower older consumers and improve health outcomes, a consumer-friendly personal health record (PHR) is needed. The purpose of this article was to evaluate PHR technology and content for older community-dwelling consumers. Specific aims were to: (a) develop a secure, web-based application for a PHR to enable interoperable exchanges of data between consumers and clinicians; (b) develop structured, evidence-based shared care plan content for the PHR using an interface terminology standard; and (c) validate the shared care plans with consumers. An interoperable web-based form was developed. The standardized PHR content was developed by expert panel consensus using the Omaha System problem list and care plans, and validated by consumer interviews. Evidence-based shared care plans for 21 problems common among community-dwelling older adults were developed and encoded with Omaha System terms for data capture in the PHR. An additional problem, Neighborhood-workplace safety, was identified by consumers and will be added to the care plans.

Nurse managed wellness centers (NMWCs) are academic service settings where baccalaureate nursing students gain rich community health clinical experience while providing valuable wellness services to a vulnerable population. The Omaha System provides a framework for generating meaningful data that is essential for describing the value of NMWCs. A retrospective study of Omaha System assessments from 9 NMWCs provides descriptive data about the characteristics of the patient population and patient outcomes in relationship to knowledge, behavior, and status. Patients showed significant improvement for the overall sample and for 6 important health problems. These findings support anecdotal data about the value of NMWC for a vulnerable population. Research for this article was funded in part by a grant from HighMark.

The partnership has 3 components: • a multidisciplinary scientific team of University of Minnesota researchers with experience in advanced data analysis and data mining techniques • a group of affiliate members from 5 countries who contribute clinical Omaha System data, suggest important clinical questions, and work together with the scientific team on research and evaluation projects • a warehouse of de-identified clinical Omaha System data including client problems, signs/symptoms, interventions, and knowledge, behavior, and status outcomes

Benchmark client outcomes across public health nursing (PHN) agencies using Omaha System knowledge, behavior, and status ratings as benchmarking metrics.A descriptive, comparative study of benchmark attainment for a retrospective cohort of PHN clients (low-income, high-risk parents, primarily mothers) from 6 counties.Omaha System Problem Rating Scale for Outcomes data for selected problems. Benchmark measures were defined as a rating of 4 on a scale from 1 (lowest) to 5 (highest).Family home visiting services to low-income, high-risk parents.The highest percentage of benchmark attainment was for the Postpartum problem (knowledge, 76.2%; behavior, 94.0%; status, 96.6%), and the lowest was for the Interpersonal relationship problem (knowledge, 21.7%; behavior, 69.0%; status, 40.7%). All counties showed significant increases in client knowledge benchmark attainment, and 4 of 6 counties showed significant increases from baseline in behavior and status benchmark attainment. Significant differences were found between counties in client characteristics and benchmark attainment for knowledge, behavior, and status outcomes.There were consistent patterns in benchmark attainment and outcome improvement across counties and family home visiting studies. Benchmarking appears to be useful for comparison of population health status and home visiting program outcomes.

Time and motion (T&M) studies provide an objective method to measure the expenditure of time by clinicians. While some instruments for T&M studies have been designed to evaluate health information technology (HIT), these instruments have not been designed for nursing workflow. We took an existing open source HIT T&M study application designed to evaluate physicians in the ambulatory setting and rationally adapted it through empiric observations to record nursing activities in the inpatient setting and linked this instrument to an existing interface terminology, the Omaha System. Nursing activities involved several dimensions and could include multiple activities occurring simultaneously, requiring significant instrument redesign. 94% of the activities from the study instrument mapped adequately to the Omaha System. T&M study instruments require customization in design optimize them for different environments, such as inpatient nursing, to enable optimal data collection. Interface terminologies show promise as a framework for recording and analyzing T&M study data.

Summary Objectives: To develop evidence-based standardized care plans (EB-SCP) for use internationally to improve home care practice and population health. Methods: A clinical-expert and scholarly method consisting of clinical experts recruitment, identification of health concerns, literature reviews, development of EB-SCPs using the Omaha System, a public comment period, revisions and consensus. Results: Clinical experts from Canada, the Netherlands, New Zealand, and the United States participated in the project, together with University of Minnesota School of Nursing graduate students and faculty researchers. Twelve Omaha System problems were selected by the participating agencies as a basic home care assessment that should be used for all elderly and disabled patients. Interventions based on the literature and clinical expertise were compiled into EB-SCPs, and reviewed by the group. The EB-SCPs were revised and posted on-line for public comment; revised again, then approved in a public meeting by the participants. The EB-SCPs are posted on-line for international dissemination. Conclusions: Home care EB-SCPs were successfully developed and published on-line. They provide a shared standard for use in practice and future home care research. This process is an exemplar for development of evidence-based practice standards to be used for assessment and documentation to support global population health and research.

The Omaha System is one of the most widely used standards for documentation in community-based settings. While researchers have focused upon this extensible classification scheme to understand and summarize structured data, few studies have analyzed the use of associated text. Two years of client records were accessed from two diverse sites utilizing the Omaha System 2005 revision: a skilled homecare, hospice, and palliative care program and a maternal child health home visiting program. Each problem allows users to enter text data for “other” signs and symptoms (S&S). Problems with the most frequent use of Other S&S were analyzed by a group of content experts to categorize associated text and inform future standard refinements. Text entries for Other S&S frequently contained duplicate entries, multiple concepts, medical diagnoses, interventions, or comments. A number of potential new and modified S&S were identified. Text entries for Other S&S appear valuable for informing future standard development.

Objective: To test the feasibility of representing public health nurse (PHN) manager interventions using a recognized standardized nursing terminology. Design and Sample: A nurse manager in a Midwest local public health agency documented nurse manager interventions using the Omaha System for 5 months. Analytic Strategy: The data were analyzed and the results were compared with the results from a parallel analysis of existing PHN intervention data. Results: Interventions for 79 “clients” (projects, teams, or individuals) captured 76% of recorded work hours, and addressed 43% of Omaha System problems. Most problems were addressed at the “community” level (87.1%) versus the “individual” level (12.9%). Conclusions: Nursing practice differed between the 2 knowledge domains of public health family home visiting nursing and public health nursing management. Standardized nursing terminologies have the potential to represent, describe, and quantify nurse manager interventions for future evaluation and research.