"Meaningful use" quickly became the most important new term in informatics language after it was included in the American Recovery and Reinvestment Act of 2009, Public Law 111-5. That law includes $19.5 billion for health information technology. It authorizes the Centers for Medicare & Medicaid Services to provide reimbursement incentives for eligible professionals and hospitals who become "meaningful users" of certified electronic health record (EHR) technology in three stages (2011, 2013, 2015). Medicare reimbursement focuses on physicians, while Medicaid reimbursement also includes dentists, certified nurse-midwives, nurse practitioners, and physician assistants.1
Meaningful use suggests that better healthcare does not come solely from the adoption of technology itself, but through interoperability or the exchange and use of health information to best inform clinical decisions at the point of care. Meaningful use incorporates complex processes and workflow involving nurses and healthcare practitioners; all providers should be considering how they can be involved, regardless of their work site. The Markle Foundation2 proposed that patient-centered, meaningful use of health information technology demonstrates that the provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs. To achieve meaningful use, quality measures must be converted to EHR metrics. In October 2009, David Blumenthal, national coordinator for Health Information Technology, US Department of Health and Human Services, said, "The key to meaningful use is to know how to measure for performance and to be able to give feedback to providers."3(p1)
Meaningful use is based on a matrix of priorities that flows from National Quality Forum work published during 2008. The cornerstones of the matrix are (1) improve quality, safety, efficiency, and reduce health disparities; (2) engage patients and families; (3) improve care coordination; (4) improve population and public health; and (5) ensure privacy and security protections.1 The matrix includes detailed goals, objectives, and measures to operationalize the cornerstones.
Numerous federal agencies, standards groups, and membership organizations are actively involved in developing and responding to aspects of meaningful use. On December 30, 2009, the Office of the National Coordinator issued the Interim Final Rule and Notice of Proposed Rulemaking, a lengthy document that addresses the definition of meaningful use, standards, certification, and the relationship of EHRs to Medicare and Medicaid. Many additional rules and regulations will be issued. The Certification Commission for Health Information Technology is currently authorized to test and certify clinical information systems. Healthcare Information Technology Standards Panel (HITSP), a public-private partnership organization, has been harmonizing standards since 2006. The National Quality Forum will continue to endorse quality measures and work in partnership with the Agency for Healthcare Research and Quality to develop a data model for quality measurement.1
The Alliance of Nursing Informatics (ANI) is a collaborative of 25 organizations that speaks as a unified voice for nurses employed in practice, education, and industry. In October 2009, ANI published a document stating that "'meaningful use' of EHR systems should strive for nothing less than an integrated healthcare community that is patient centered and promotes usable, efficient, and seamless information flow."4(p65) The ANI indicated that nurses are instrumental in coordinating care across the continuum and connecting acute, ambulatory, long-term, community, home care, and public health-based settings. The ANI stated that the use of standardized nursing and other health terminologies "is necessary and a prerequisite for decision support, discovery of disparities, outcomes reporting, improving performance, maintaining accurate lists of problems and medications, and the general use and reuse of information needed for quality, safety, and efficiency."4(p66)
Currently, the American Nurses Association (ANA) recognizes 12 reference and interface terminologies. SNOMED CT is an example of a reference terminology; it consists of 310 000 active concepts organized into hierarchies, descriptions, relationships, and attributes that are not visible to the practitioner. The seven interface terminologies recognized by ANA are Clinical Care Classification, International Classification of Nursing Practice, NANDA International, Nursing Interventions Classification, Nursing Outcomes Classification, Omaha System, and Peri-operative Nursing Data Set.5,6
Interface or point-of-care standardized terminologies are an important component of EHRs that enable capture and representation of assessment, service, and outcome data. Point-of-care terminologies and standardized care plans or pathways are keys to advancing the federal mandate described in this article because they enable meaningful translation of care concepts to data. Nurses and other healthcare practitioners use such terminologies to describe, document, and quantify their daily practice in a consistent manner. When practitioners use point-of-care terminologies in an EHR accurately and consistently, they generate a quality database that reflects the needs of their patient population. Such data can be used to monitor quality of care, client health outcomes, and population health trends. In addition, clinical data from various groups can be mapped to the reference terminologies.
THE OMAHA SYSTEM
The Omaha System is one of the point-of-care terminologies recognized by ANA and referred to in the ANI document. It includes characteristics described for meaningful use in that 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. The Omaha System is congruent with standards mandated by the Office of the National Coordinator, integrated into SNOMED CT and Logical Observation Identifiers, Names, and Codes (LOINC), registered by Health Level Seven (HL7), and listed in HITSP Use Cases.7
The Omaha System originated at the Visiting Nurse Association of Omaha (Nebraska) as a collaborative effort between interdisciplinary practitioners and researchers. Four research studies conducted between 1975 and 1993 were federally funded. DeLanne Simmons, chief executive officer, envisioned a computerized management information system that incorporated an integrated, valid, and reliable clinical information system focused on patients who received services, not the practitioners who provided the services.7,8
The Omaha System exists in the public domain (open source, no fee) and enhances practice, documentation, and information management. It was designed to be relatively simple, hierarchical, multidimensional, and computer-compatible and used by interdisciplinary practitioners to document and communicate information about patient care from admission to discharge. It is intended for use across the continuum of care. It is based on a conceptual model depicted in Figure 1 that reflects the pivotal position of the individual, family, and community; the partnership with practitioners; and the value of the problem-solving process.7,8 That model reflects the meaningful use matrix of priorities.
The Omaha System consists of three relational, valid, and reliable components designed to be fully integrated:
* Problem Classification Scheme (patient-centered assessment that engages the patients and their families)
* Intervention Scheme (plans, pathways, service delivery to improve safety, quality, and effectiveness)
* Problem Rating Scale for Outcomes (evaluation that provides usable information for quality improvement)
The Problem Classification Scheme is a hierarchy that includes domains; patient-, family-, and community-centered problems; modifiers; and signs/symptoms. The Intervention Scheme is a hierarchy of interventions that includes categories, targets, and patient-specific information. The Problem Rating Scale for Outcomes consists of knowledge, behavior, and symptom status concepts and Likert-type rating scales. A detailed description of the purpose, terms, definitions, codes, automation, and users is available on the Omaha System Web site and book.7,8
Promoting the appropriate use of health information technology is essential. During a 2009 Institute of Medicine workshop9 that addressed cost, quality, safety, outcomes, and innovation, health information technology was the most commonly mentioned priority. Implementing a point-of-care terminology such as the Omaha System to structure clinical documentation is also a priority for practice, education, and research. Use of the Omaha System generates detailed standardized data that describe health-related problems, services, and outcomes. These data can be used for meaningful use applications such as exchange of patient and population information, healthcare quality evaluation, and health services research. Adoption of the Omaha System in practice, education, and research has increased steadily since 1990, in part due to its incorporation as the point-of- care terminology in clinical software systems. Almost 300 articles, chapters, and books written by national and international authors are listed on the Web site, a reflection of its widespread adoption.
MEANINGFUL USE OF THE OMAHA SYSTEM
Rapid advances in informatics and implementation of EHRs have advanced the meaningful use of patient data. Such EHRs provide a mechanism for disseminating agency standards of care and generating clinical data. Large practice-generated Omaha System data sets are available for program evaluation and research. Healthcare leaders are using the Omaha System as a tool to address the meaningful use goals: monitor and enhance care quality, efficiency, and value; engage patients and families; improve care coordination; and promote population health.9 For example, Minnesota public health agencies have used Omaha System data to inform and communicate clinical decisions at the point of care. In particular, Washington County Minnesota Public Health and Environment administrators, managers, nurses, and other public health professionals worked together to establish a comprehensive, agency-wide outcomes management system based on the Omaha System.10,11
Diverse stakeholders from clinical settings, education, research, and informatics have formed Omaha System users groups to advance practice and meaningful use. Groups in Minnesota and Washington are especially active. In Minnesota, collaborative Omaha System data quality and practice enhancement efforts began in 2001 and continue to expand to diverse agencies and programs. Four public health nursing agencies identified the needs of home-visiting patients across county public health agencies and demonstrated outcomes of services. Behavioral, psychosocial, environmental, and physiological problems were similarly identified and addressed in all agencies. Statistically significant improvement in patient health problems occurred consistently across agencies. Problems involving antepartum/postpartum and family planning showed the greatest improvement; the problems neglect and substance use showed the least improvement. Based on these findings, the agencies prioritized strategies for enhancing home-visiting interventions.12,13 The Minnesota Department of Health worked together with the Minnesota Omaha System Users Group to gather data to evaluate a statewide home-visiting program.
In one Minnesota county, the Omaha System was used to engage seniors in health promotion activities and develop and evaluate community-level interventions addressing chronic health problems at senior high-rise clinics. At senior blood pressure clinics, the standardized protocol assessed four problems: circulation, medication regimen, communication with community resources, and mental health, plus a monthly teaching topic (eg, blood pressure self-care). Seniors responded positively to the health promotion clinics and actively engaged in monitoring their personal health. Analysis of data from senior clinics showed that the most common problems were pain and neuromusculoskeletal function. Public health nurses used these findings to tailor the program interventions and to improve care coordination and communication about their program with local physicians.14
Similarly, efforts are under way to improve population health using the Omaha System. Maine Centers for Disease Control used the Omaha System to create practice standards for tuberculosis direct observed therapy, generate outcomes data, and report community-level outcomes to administrators and decision makers.15 In Minnesota, a work group composed of local and state public health agency personnel, asthma experts, nursing researchers, and graduate students developed and tested best practices pathways for asthma care at the individual and community levels. These pathways are available online for incorporation into any documentation system. Public health and home care agencies in Minnesota and Washington developed more than 130 standard pathways that are available on the Minnesota Omaha System Users Group Web site. The pathways are related to topics, such as disease investigation, perinatal hepatitis B, refugee health, public health nuisance, and elderly case management services, and to programs, such at the Nurse Family Partnership and the Minnesota Family Home Visiting Program. Washington agencies created shared home-visiting "core" pathways for use throughout the state that address nine priority problems: pregnancy, postpartum, caretaking/parenting, income, mental health, abuse, neglect, healthcare supervision, and substance use.14 Using the Omaha System facilitated needs assessment, program evaluation, and outcomes management processes for these agencies and will continue to play an integral role in guiding practice, increasing the value of services, and thus improving patient and population outcomes.
Informatics is revolutionizing nursing education in the United States and globally; it affects all educators, students, and aspects of curricula.16 Informatics is now listed as one of the six competencies that graduates must have to function effectively; the other competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, and safety.17 These competencies parallel the meaningful use matrix of priorities and the Omaha System.
Educators have been involved with the Omaha System in a variety of ways. Some participated in the federally funded developmental research conducted between 1975 and 1993. During the 1980s, faculty members began introducing students to the Omaha System, primarily in the community health course. Gilbey18 and her New Brunswick, Canada, colleagues introduced the Omaha System to increase students' assessment skills.7,8 The focus was on professional practice, quality care, decision-making skills, standardized documentation, and communication. Since then, use expanded to include many nursing programs in the United States and some schools internationally and includes diploma, associate degree, baccalaureate, master's, and doctoral programs. As healthcare professionals increase their collaborative use of clinical information systems, nursing educators are introducing colleagues and students from other disciplines to the Omaha System. Currently, faculty include the concepts of meaningful use by emphasizing a problem-solving approach to practice, partnerships with patients, benefits of efficient and effective documentation, an outcomes orientation, and the value of using standardized health information to inform clinical decisions at the point of care.19
Increasingly, educators in the United States and globally embrace the Omaha System, EHRs, and the Internet as essential components of curricula. The Omaha System has been introduced to promote clinical reasoning, structured documentation, and research globally; educators and students in Australia, Hong Kong, Iceland, Japan, Korea, Turkey, New Zealand, Taiwan, the Netherlands, and United Kingdom have published articles, chapters, and books about their experiences. Educators recognize the value in offering students hands-on informatics experiences in learning laboratories and clinical sites. More than 50 schools in the United States and New Zealand used FITNE's Nightingale Tracker, in addition to San Jose State University School of Nursing; schools are now developing or purchasing more sophisticated Omaha System software.7,8
The University of Wisconsin-Milwaukee College of Nursing established its first primary care nurse-managed center in 1986. Although the primary goal was to provide high-quality services for individuals and families who had serious health-related problems, the secondary goal was to establish a repository that faculty and students could use to integrate clinical, financial, and statistical data. Educators selected the Omaha System to standardize practice, documentation, and information management and now have a 24-year data repository to analyze. Approximately 20 University of Wisconsin-Milwaukee educators, doctoral students, and master's students have conducted research based on the Omaha System. In addition to nursing students, medical, social work, and health career students are introduced to the Omaha System during clinical experiences at the centers.7,8
San Jose State University School of Nursing, San Jose, CA, is an exceptional Omaha System educational site that exemplifies concepts of meaningful use. Early in the 1990s, faculty leaders recognized that it was time to embrace new practice models such as nurse-managed centers, the Omaha System, and informatics. They decided to integrate concepts in their curriculum and implement the Omaha System at their centers.
Collaboration is one of the reasons that the San Jose State University-Omaha System action plan has been successful. Educators purchased books, scheduled their first consultation and workshop in 1994, and published their first Omaha System-related article in 1998.20 To date, faculty and students published more than 15 related articles and chapters, presented numerous posters and speeches, conducted 10 studies, shared case studies on the Omaha System Web site, and will be the host school for the 2011 Omaha System International Conference.21,22 San Jose State University-Omaha System obtained grants to buy FITNE's Nightingale Tracker in 1998, the first Omaha System-based point-of-care technology developed explicitly for student use, and was one of the seven FITNE Centers of Excellence. The school purchased a more sophisticated Web-based clinical information system in 2008. A faculty member was one of the leaders who incorporated the Omaha System into the baccalaureate curriculum essentials for their national psychiatric-mental health specialty in 2008.23 Educators and students have received public media coverage on campus, locally, at the state level, and nationally. They encouraged area practice sites to consider using the Omaha System and provided ongoing support as those sites began purchasing software. Nursing faculty developed partnerships with communication disorders, speech and language pathology, and chiropractor colleagues to introduce their students to the Omaha System.
A substantial body of research exists that demonstrates the meaningful use of the Omaha System. Studies span the care of the low-birth-weight infants, perinatal and postpartum women, chronically ill elders, and patients at the end of life. Settings include acute care, home care, primary care, nurse-managed centers, public health, school nursing, and the community. The Omaha System offers a powerful strategy to document the details of a clinical research intervention and describe what happened, when, where, how, and to whom. Using the Omaha System to document care enables researchers to examine the relationship between patient complexity, nursing interventions, and patient outcomes.
The Transitional Care Model created and tested by an interdisciplinary team of researchers led by Dr Mary Naylor at the University of Pennsylvania School of Nursing uses the Omaha System to document the care provided by advanced practice nurses as they implement the Transitional Care Model.24 The Omaha System is the core component of the clinical information system that captures the numbers, types (hospital, home, and physician office), timing, length, and the focus of each visit. Advanced practice nurses use Omaha System patient problems and corresponding interventions to document the care they provide. In the clinical information system, the meaningful use of the Omaha System supports the transfer of information from hospital to home, skilled nursing facility, or nursing home, therefore playing a major role in continuity of care and communication of the plan of care from one setting to another. In addition, the rating of the patients' knowledge, behavior, and status of symptoms related to each Omaha System problem gives practitioners a clear, objective measure of the baseline condition. Rating these concepts again at intervals or at discharge enables comparisons of progress or decline useful for quality monitoring and evaluating the effectiveness of nursing interventions and progress toward patient goals.
To date, the University of Pennsylvania teams have used the Omaha System and demonstrated its usefulness in acute care and home care and in supporting continuity of care across settings through multiple studies with nearly 1000 patients. Two recently completed studies used the Omaha System to document care of cognitively impaired and psychiatric patients, demonstrating its usefulness with challenging populations.19,25
An Omaha System state-of-the-science research review was published in 2005; the review noted that more than 40 unique studies were conducted between 1982 and 2003.8 Studies with components of meaningful use were categorized as those that describe patient problems, clinical practice, patient outcomes, and healthcare resource utilization. Additional studies noted in the chapter advanced the science of nursing classification and use of the Omaha System in education.
A MEDLINE search on the keyword Omaha System and limited to the years 2005-2010 returned many additional studies since the last published review. Many studies are related to the cornerstones of meaningful use. These include studies that use Omaha System data to describe clinical care and patient outcomes26 and others that extend the science of classification or terminology development.27 Additional examples are studies that involve effectiveness research and data mining,28,29 quality measurement,22 and predict patient outcomes.30 Students continue to develop new programs of research with multiple dissertations completed and under way nationally and internationally. Furthermore, educators at a variety of universities worldwide are currently conducting Omaha System studies.
Several recently completed studies clearly demonstrate that the Omaha System can generate data congruent with meaningful use. A data mining study29 provides an example of the increasing rigor of Omaha System research. Study findings revealed clusters of patients who differed significantly in demographics, services, baseline and final scores on the Problem Rating Scale for Outcomes, Omaha System problems, and signs and symptoms. This type of analysis can elucidate the resources needed for various patient clusters and patterns of interventions provided. Such analysis is valuable when agencies examine their staffing patterns in relation to the number of staff and the skill mix needed to care for their patients.
Westra et al30 focused on the use of secondary data to predict outcomes for older adults receiving home care services. Their study compared outcome data obtained by using the Omaha System and the Centers for Medicare & Medicaid Services' OASIS tool. Agency staff abstracted data from the EHRs of 133 patients and compared improvement in pain between the Omaha System problem, pain, and the OASIS pain outcome scores. Based on chart reviews, nurse managers concluded that the Omaha System data were a more accurate reflection of patients' pain status than the OASIS data. In-service education sessions were conducted with staff to share the findings and develop consistent guidelines for documentation of OASIS, followed by monthly monitoring. A comparison of the Centers for Medicare & Medicaid Services outcome reports demonstrated improved documentation of pain management from 45% in the first year to 64.5% in the second year. Findings from this study support the value of the Omaha System for conducting quality improvement studies.
Barkauskas et al27 demonstrated an opportunity to increase meaningful use within nurse-managed centers. Only 31% of the 60 centers that responded to a national survey were using a standardized language. Of these, the majority (70%) were using the Omaha System. This reveals substantial opportunities to increase the use of the Omaha System within the remaining 69% of nurse-managed centers and therefore gain the meaningful use benefits afforded by a standardized language to understand the unique contribution of nursing to quality patient care.
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. This article provides national and international examples across a variety of healthcare settings and patient populations. The examples illustrate the federal initiative to invest in information technology and promote meaningful use: a patient-centered, interdisciplinary approach to care; improved workflow and communication; and use and reuse of information. The examples are congruent with the cornerstones of the National Quality Forum matrix by enhancing clinical decisions at the point of care, increasing the quality of care, promoting interoperability, and decreasing costs.
For 4 decades, nurses have provided visionary leadership in the creation and use of point-of-care terminologies such as the Omaha System. Today, nurses in practice, education, and research settings are leaders as they develop tools and methods to support meaningful use of the structured data generated by these terminologies. Nurses are needed as active participants in advancing the robust science of nursing informatics within organizations and practice communities, locally, nationally, and globally. National and international developments have the potential to increase interoperability and improve the quality of care.