Transforming Clinical Practice through TerminologyHINZ 2010Sheree East Director of Nursing<br />
Transformation <br />
LOCAL GROUND FAILURE<br />
Through The Looking Glass<br />
Why Transform?<br />BETTER SOONER MORE CONVENIENT <br /><ul><li>Improved patient experience
Safe quality services
Integrated Family Health Care & service coordination
Need for community care health outcome data
Need to share health information </li></li></ul><li>Project GAIN<br /><ul><li>Improve clinical care
transform what and how clinicians document
prompt and provide tools to assist achievement of  outcomes
Describe what nurses and allied health professionals
Describe outcomes of care
Enable Information sharing / Interoperability with wider health sector
Use best practice and national / international standards and tools
GAIN: Getting Access to Information NOW</li></li></ul><li>
Omaha System:  What We Do<br />4 ‘domains’ – the ‘who’ and ‘where’ of healthcare<br />environment, physiological, psycho-s...
Treatment and procedures
Case Management
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Transforming Clinical Practice through Terminology

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Sheree East
Director of Nursing, Nurse Maude
(4/11/10, Illott, 12.00)

Published in: Health & Medicine
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  • We’re facing a new and largely unknown world in healthcare and we need transformers to deliver care in the new landscape.
  • In 2009 Nurse Maude commenced a project with the end goal to improve clinical practice through the use of a clinical information system. The clinical system was also viewed as an opportunity to improve data capture and outcome reporting on the care delivered. Informatics Nurse Brent McGrath presented last year at HINZ on the development of this project and his sudden death this January has been a huge blow in losing such an intelligent and talented nurse. I would especially like to acknowledge his work which has shaped the project and led us on the pathway we are continuing on. I also would like to acknowledge my colleagues Shona Wilson, Kay Poulsen and US colleague Karen Monsen for their insights. The project set out to Improve clinical care through developing standardised and systematically designed documentation using recognised systemsetc
  • We have completed the first stage of the project and recently commenced stage two. The first stage of the project included:Aligning the terms of the Omaha System, with the terms of the Nurse Maude clinical guidelines and SNOMED-CT as they relate to concepts and definitions.Aligning the Client Assessment Protocol Summary (CAP) triggers from InterRAI tools (Minimum Data Set – Homecare (e.g. MDS-HC), with the problem classification scheme of the Omaha System, Nursing Outcomes Classification Scheme (NOC) and SNOMED-CT concepts toward common terms.Undertaking a workshop with expert community care clinicians to establish congruency between the terms and the colloquialisms of current practice to develop the terms and descriptions of the dataset.Development of the CADI data set
  • Transforming Clinical Practice through Terminology

    1. 1. Transforming Clinical Practice through TerminologyHINZ 2010Sheree East Director of Nursing<br />
    2. 2.
    3. 3. Transformation <br />
    4. 4. LOCAL GROUND FAILURE<br />
    5. 5. Through The Looking Glass<br />
    6. 6. Why Transform?<br />BETTER SOONER MORE CONVENIENT <br /><ul><li>Improved patient experience
    7. 7. Safe quality services
    8. 8. Integrated Family Health Care & service coordination
    9. 9. Need for community care health outcome data
    10. 10. Need to share health information </li></li></ul><li>Project GAIN<br /><ul><li>Improve clinical care
    11. 11. transform what and how clinicians document
    12. 12. prompt and provide tools to assist achievement of outcomes
    13. 13. Describe what nurses and allied health professionals
    14. 14. Describe outcomes of care
    15. 15. Enable Information sharing / Interoperability with wider health sector
    16. 16. Use best practice and national / international standards and tools
    17. 17. GAIN: Getting Access to Information NOW</li></li></ul><li>
    18. 18. Omaha System: What We Do<br />4 ‘domains’ – the ‘who’ and ‘where’ of healthcare<br />environment, physiological, psycho-social, behaviours<br />42 ‘problems’ – the ‘what’ we see (signs & symptoms)<br />4 intervention categories<br /><ul><li>Teaching, guidance & counselling
    19. 19. Treatment and procedures
    20. 20. Case Management
    21. 21. Surveillance</li></ul>75 interventions – ‘when’, ‘why’, ‘how’ of what we do<br />
    22. 22. Care Coordination<br />Care Delivery<br />Clinical Coding<br />Provider Assessments<br />(InterRAI / Target)<br />Care Planning(OMAHA System)<br />Assessments & Allocations(InterRAI)<br />SNOMED-CT<br />Terminology(OMAHA System)<br />
    23. 23. Four Stage Project<br />Document Terms and Definitions and develop a community clinical data set referencing:<br />OMAHA system<br />InterRAI <br />SNOMED-CT<br />Community nursing & Allied Health documentation<br />Develop clinical record<br />Produce software specifications / requirements, develop and test the electronic prototype <br />Implementation / Roll out. Staff will be trained in the use of the mobile technology and the clinical record<br />
    24. 24.
    25. 25. The Documentation Database<br />Over 800 individual data elements across 42 forms<br />Some data elements collected several times on one form<br />Some data elements collected numerous times across the organisation (up to 46 times)<br />Thousands of separate pieces of information recorded on the forms<br />
    26. 26. Documentation Database Cont.<br />18% of the data was demographic<br />Up to 30% of other data was duplicated<br />Limited standardised information about treatment & procedures <br />No space or place to record case management, teaching, guidance & counselling<br />
    27. 27. Development of the CADI<br />
    28. 28. Data Elements <br />130 mandatory 166 non-mandatory<br />Of the mandatory items:<br /><ul><li> 49 are already present in the National Collections*
    29. 29. 19 require definition within the national collections
    30. 30. 16 are defined in the Midland Data Framework
    31. 31. 12 are defined in the Omaha System
    32. 32. 12 are provider-specific
    33. 33. 5 are defined in International Coding systems
    34. 34. 17 are boolean flags or free text fields</li></li></ul><li>CADI Categories / Entities<br />
    35. 35. THE CADI IN ACTION<br />How will the data set transform care?<br />
    36. 36. DAMAGE: CHRISTCHURCH<br />There is a crack in everything That's how the light gets in. <br />Leonard Cohen<br />
    37. 37. Thank You !<br />

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