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The Value of Incorporating The Omaha System
into a Computerized Documentation System
for Home Health Care

By Bonnie Westra, PhD, RN

Efforts are underway at the state and national levels to standardize and integrate existing databases to control costs, and assure quality and appropriateness of health care. While home health accounts for only a small proportion of the total health care dollar or $8.5 billion in 1990, it is one of the most rapidly growing areas in the health care system (JAMA, 1990; Levit, Lazenby, Cowan, & Letsch, 1991). The majority of home health care is provided or supervised by nurses, yet nursing data (nursing diagnoses, interventions, outcomes, and intensity of care) are missing in administrative and claims databases used to describe quality and cost-effectiveness of care. Standardized data with uniform definitions are needed to describe the effectiveness and costs associated with home health care.

Classification Systems of Nursing Information

The nursing care elements of the Nursing Minimum Data Set (NMDS) provide a framework for essential data needed to complement existing databases used to describe the quality and cost-effectiveness of home care (Werley, Devine, Zorn, Ryan, & Westra, 1991). These data elements are nursing diagnoses, nursing interventions, outcomes, and intensity of nursing care. Classification systems for standardizing language within these data elements have been developed, four of which are advocated by the American Nurses' Association (ANA). These include the North American Nursing Diagnosis Association (NANDA) list of nursing diagnosis, the Nursing Intervention Classification (NIC) system, the Home Care Components System, and the Omaha System.

The first two systems recommended by the ANA cover only one data element of the four NMDS nursing care elements. The Home Care Component System (Saba, 1991) includes classification systems for nursing diagnoses and interventions, and rates outcomes. The HCC System incorporates an adapted version of the NANDA nursing diagnoses. Nursing interventions, which were abstracted from Medicare charts, are similar in format to the Omaha System wherein they are first coded into four major categories, then into more specific actions. Expected outcomes (goals) are identified and coded as improved, stabilized, or deteriorated. Since this system was developed only recently using data only from Medicare clients, it needs further testing to demonstrate usefulness within home health care in general.

The OMAHA system was developed through successive federally funded grants for community health (Martin & Scheet, 1992). It includes three of the NMDS nursing care elements - nursing diagnoses, interventions, and outcomes. There are 44 nursing diagnoses, four major intervention categories with 63 more specific targets (actions), and three outcomes (knowledge, behavior, and status) which are measured for each identified problem on a five-point likert scale. These three components were inductively derived from community health records to capture the language of practicing nurses. Successive studies were conducted to establish the validity and reliability of these systems and coding schemes have been developed for ease of data collection. The Omaha system is one method for providing uniform categories and definitions for three of the NMDS nursing care elements in a home health documentation system. Therefore, the Omaha System was chosen for incorporation into CareFacts HC, the home care documentation program developed by Epsilon Systems, Inc.

Nursing Diagnoses

The Omaha Problem Classification Scheme is composed of four domains and then distinct problems (diagnoses) within each domain. The four domains represent community health practice and are: Environmental, Psychosocial, Physiological, and Health Related Behaviors. Problems within each domain can be rated as actual (deficit), potential, or health promotion, as well as whether the problem is an individual problem or a family problem.

Interventions

When selecting interventions in the Omaha System, the nurse first selects one of the four major categories:

Health Teaching, Guidance, and Counseling;

Treatments and Procedures;

Case management; or

Surveillance (assessment and monitoring).

The nurse then selects one or more intervention targets that directs the action the nurse will take in caring for the patient.

Outcomes

In the Omaha System, outcomes are rated for each problem on a five-point likert scale in terms of knowledge, behavior, and status.

Benefits

A number of benefits are anticipated from the development of a computerized documentation system which incorporates standardized data using the Omaha System (Clark & Lang, 1992; Werley et al., 1991). It is assumed that documentation in home care is the foundation for aggregated data to validly describe practice. For staff nurses, standardized language would provide a framework and structure for documenting care, provide useful information for clinical decision making, facilitate continuity of care among and across agencies, and facilitate monitoring of effective care. The use of standardized data is expected to decrease documentation time and prepare the industry for the future when the electronic medical record will be used for documentation of care across settings. The end result is improved client care from better and more accessible information.

For home health administrators a computerized documentation system incorporating standardized data would be useful for describing the case mix of clients and planning for staffing needs. Standardized data also would facilitate total quality management activities, such as comparing the outcomes for groups of clients with similar conditions. Comparisons of the cost-effectiveness of care when different interventions are used to treat similar conditions could be made once data are standardized. Based on trends over time, administrators would be able to project future trends for program planning.

Under state and federal health care reform measures, there is an effort to integrate existing sources of data. Valid data about home health are missing and inclusion of the standardized data about the nursing care of client in home health would add to that effort. Comparisons of practice across home health agencies, geographical locations, and reimbursement programs could be made. As a result health planners could use this data to assure quality of care, control costs, and develop appropriate health policies. The end result would be the improvement of health care for consumers in community settings. The use of standardized data also would allow research about quality and cost-effectiveness of care to be conducted more inexpensively, since data bases could be constructed across agencies and contain large numbers of subjects, provide a longitudinal record of episodes of care, and represent a more universal population (AHCPR, 1991).

References

Agency for Health Care Policy and Research [AHCPR]. (1991). Report to Congress: The feasibility of linking research-related data bases to the Federal and non-Federal medical administrative data bases. U. S. Department of Health and Human Services, Public Health Service (AHCPR Pub. No. 91-0003). Rockville, MD: Agency for Health Care Policy and Research.

Clark, J., & Lang, N. (1992). Nursing's next advance: An international classification for nursing practice. International Nursing Review, 39, 109-112.

JAMA. (1990). Home care in the 1990's. JAMA, 263, 1241-1244.

Levit, K. R., Lazenby, H. C., Cowan, C. A., & Letsch, S. W. (1991). National health expenditures. Health Care Financing Review, 13(1), 29-54.

Martin, K. S., & Scheet, N. J. (1992). The Omaha System: Applications for community health nursing. Philadelphia: Saunders.

Saba, V. K. (1991). Develop and demonstrate a method for classifying home health patients to predict resource requirements and to measure outcomes. Springfield, VA: National Technical Information Service.

Werley, H. H., Devine, E. C., Zorn, C. R., Ryan, P., & Westra. B. L. (1991). The Nursing Minimum Data Set: Abstraction tool for standardized, comparable, essential data. American Journal of Public Health, 81, 421-426.

Citation: Westra, B. (1993). Critical Pathways In Home Care, The Quality Messenger, 1(1), 1, 6, 8.

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