CHAPTER 22

COMMUNITY HEALTH APPLICATIONS

CHNIs a synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations.It requires a comprehensive understanding and knowledge of the framework of the community, its resources , and the sociocultural issues impacting people within the community.The focus is on the population.The standards of CHN incorporate health promotion, health maintenance, health education, health management,coordination,and continuity of care using holistic approach.

Data SetsUniform data set is a minimum set of items of information with uniform definition and categories, concerning the specific dimension of the service or practice setting that meets the essential information needs of multiple data users within the scope of the service or practice setting.

Criteria that define a data set may include:• Utility for multiple users• Terms that can be defined and measured• Common or shared language that is universally

understood • Relevance to national or local needs• Uniformity with other applicable data sets• Data can be structured in compliance with Health Insurance

Portability and Accountability Act (HIPAA)• Data can be collected easily and accurately through the

functions of service delivery

Selected Data Sets The nursing minimum data set (NMDS) developed by

Werley and Lang(1988) was designed for all healthcare settings but focused primarily on the hospital setting.

1. Uniform Data Set for Home Care And Hospice Organizational Individual

2. Outcome and Assessment Information Set (OASIS) Outcome- Based Quality Improvement (similar to a data set) It included two components: outcome analysis outcome enhancement

Four- prong effort to improve the quality of care for consumers:

Regulation and enforcement activities conducted by state survey agencies and CMS

Improved consumer information on the quality of care provided by HHAs

Continual community-baes quality improvement programs for HHAs

Collaboration and partnership to leverage knowledge and resources (CMS,2003)

3. Health Plan Employer Data and Information Set (HEDIS)

Vocabulary Languages

Are validated clinical reference languages, taxonomies, or terminologies that make healthcare knowledge more usable and accessible.

2 Common Nursing Vocabularies or Taxonomies in use for CHN:

Clinical Care Classification (CCC) system

Omaha System

Clinical Care Classification SystemPreviously known as the HHCC (Home Health Care Classification).

CCC is designed to document, code, and classify for computer-processing patient care in any clinical setting by any healthcare provider using standardized framework.

Consisting of 2 interrelated taxonomies:CCC of Nursing Diagnosis

CCC of Nursing Interventions

CCC of Nursing Diagnoses-consist of 182 (59 major and 123 subcategories) nursing

diagnoses and /or patient problems.

3 modifiers:• Improve patient’s condition• Stabilize patient’s condition• Support the patient’s deteriorating condition

CCC of Nursing Interventions-consists of 198 (72 major and 126 subcategories) nursing

interventions or services.

4 modifiers:Assess or monitor

Care or perform

Teach or instruct

Manage or refer to depict the type of intervention actions.

21 Care Components:ActivityBowel / GastricCardiacCognitiveCopingFluid volumeHealth behaviorLife cycleMedicationNutritional

Physical regulationRole relationshipRespiratorySafetySelf-careSelf-conceptSensorySkin integrityTissue perfusionUrinary elimination

CCC uses the nursing process for its conceptual model with different labels for its 6 phases

1. Care components (assessment)

2. Diagnoses / problems (diagnosis)

3. Expected outcome (outcome identification)

4. Nursing interventions (planning)

5. Type action (implementation)

6. Actual outcome (evaluation)

CCC Uses

• Used by numerous by vendors of IT systems to document healthcare manually or electronically.

• Used in all types of healthcare settings for documenting patient care and for implementing decision support and evidence-based practice modules.

• Used in numerous research studies such as a study by Holzemer of AIDs patients with pneumonia.

• Being used in nursing education.

Clinical Care PathwayAn emerging use being offered by IT vendors for the

CCC is as an application for clinical care pathway (CCP).

A CCP can provide the standardized framework for linking and tracking the care process.

In a CCP, the 21 care components are used to correlate the assessment data for a medical condition.

The CCP is used to identify the interventions and type of actions needed for each encounter and /or visit for the episode of care or selected time periods.

The CCC is used to improved quality, ensure safety, measure outcomes, and/or determine acuity and cost.

Omaha System

Is a research-based, comprehensive taxonomy designed to generate meaningful data following usual or routine documentation of client care.

3 Components:Problem classification schemeIntervention schemeProblem rating scale for outcomes

Community Health SystemsThe ff. are some of the typically used in CHS:

Categorical systems

Screening programs

Client registration systems

Special purpose systems

MIS’s

Statistical reporting systems

Special purpose systems

Home Health Information SystemsTime- Sharing Systems- are computer based systems develop by service bureaus that are shared by many HHA’s.Stand- Alone Systems- are commercial systems developed for direct installation and implementation in an HHA.Portability of Data- can then be transferred remotely to the main database through a client server.Point-of-care Systems- offer software-aided care planning and critical pathways allowing for care delivery.

Reimbursable Models- designed to furnish information essential for reimbursement of services provided to patients eligible for Medicare, Medicaid.Managed care- the increased of managed care in the home health arena and the PPS for home care services has had an impact on the financial and billing systems.Scheduling Systems- they are designed to scheduled the clinicians providing services with the patients requiring the visit matching the clinician capacity with the required patient care.

Telemedicine -is being implemented to replace face-to-face home visits. It

refers to the electronic transfer of medical information and services (voice, data, and video) from one site to another using telecommunication technologies.

Technologies may include: Telemonitors with peripheral biometric attachments for

remotely monitoring biophysical parameters. Videophone with two-way audio-video connectivity which

allows for the visualization of client activity. In-home message devices with disease management

education, advise, and vital sign monitoring. Video cameras for monitoring all aspects of care delivery

particularly focusing on wound management and home care aide supervision.

PCs with Internet connectivity for supervised communication Video conferencing that allows clinicians, physicians, and

other healthcare providers to communicate about patient-specific care.

Community Health Telemedicine Systems

Communication telemedicine system link patients homes to health care facilities and healthcare professionals, home care workers to their supervisors, and patients and families with community resources.

Internet ApplicationsUsing access to a computer terminal with internet applications

can be used by patients to 1. Assist in self-diagnosis and preventive medicine 2. Reduce unnecessary outpatient visits3. Provide self-directed triage4. Eliminate the “worried well” aspects of many patient-

provider interactions.

Benefits: Improved patient and provider satisfaction Patient time savings in tracking and receiving information Reduced need to see a healthcare provider “face to face” Increased reliance on computer-based information Reduced information calls More cost-effective care

Telemedicine Devices

HHAs are increasingly using devices that allows healthcare providers to communicate with patients in their homes.

Communication technology is used to transmit x-rays, electrocardiograms, and other clinical data for analysis by specialists. Electronic healthcare allows rural professionals to “see” (via two-way interactive video) more clients without having to make “home visits,” thus saving travel time and ultimately cost.

Community Health Network Systems

-is an innovative ambulatory care system specially developed to provide services by computer.

-system allows the subscribers to telephone for assistance and guidance on services offered via the terminal.

-system performs a triage of actions but not necessarily diagnoses. They include the ff:• Download the patient record from hospital to

the home database.• Enter a series of questions about symptoms

using expert system logic until the pathways are concluded.

• Track self-care and , depending on the responses to questions, call or make an appointment with a clinician.

• Provide additional information on the condition if self-care is chosen to assist the client to resolve the problems.

Home High-Tech Monitoring Systems

Home high-tech monitoring systems are using computers to link patients at home to healthcare facilities. They allow healthcare providers to monitor the progress of their patients. Monitoring systems are being used not only for diagnosis and treatment but also for prevention.

Educational Technology Systems

Educational technology applications provide communication linkages, information access, and educational materials. These technologies meet the need for clients to reach beyond their environment to “see” and “hear”.

Future Trends

Community health information networks will link multiple providers, patients information, and regulatory bodies on a single system allowing for integration of data, continuity of care, and the tracking of outcomes across service providers.

CHAPTER 23

AMBULATORY CARE SYSTEM

On April 27, 2004, President George Bush announced a goal to established electronic health records (EHRs) for all citizens within a 10 year time frame. One responsibility for the national coordinator is to improve “the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through an effective infrastructure for the secure and authorized exchanged of health care information”

The report identifies four major goals, with strategic action areas for each (Decade, 2004):Goal 1: Inform Clinical PracticeGoal 2: Interconnect cliniciansGoal 3: Personalize CareGoal 4: Improve population health

Where Ambulatory Clients are Being Treated

Organizations that fit within the umbrella of ambulatory healthcare:

Ambulatory clinicsSurgery centersSingle and multi specialty group practicesDiagnostic laboratoriesHealth maintenance organizationsIndependent physician associationsBirthing centersCollege and university health services.

Issues for Ambulatory CareIncreased accountability

Need for continuous and documented services improvements

Pressures to control utilization

Protection of confidential information.

Applications Necessary in the Ambulatory Environment

Registration

Billing accounts receivable

Accounts payable

Patient and staff scheduling

Managed care functionality

Benefits by using electronics records:1. Financial Benefits

2. Administrative Benefits

3. Clinical Benefits

Regulatory requirementsAccounting for costs can be aided by information technology. Systems must support the resource based relative value scale (RBRVS) and the relative value unit (RVU).

Implementation Issues and ChallengingIn 2004, there was a long way to go in implementing clinical EHRs in the ambulatory arena. Based on 7,808 ambulatory care facilities, in 2004 84% were not automated, 13% had software installed, and 3% had a contract signed but the software was not implemented. Only 7% planned to purchase software.

The Role of the Nurse Using Informatics Concepts in the Ambulatory ArenaThe nurse is a user of the data contained in automated

systems.

OBJECTIVES: Is to take the data and put it together in meaningful ways, making information.

An automated system can help in this management of data and the transformation from data to information to knowledge.

A nurse may be involved in the selection of an automated system based on a needs assessment of the environment.

All nurses must be mindful of the impact of the information system on the confidentiality and security of information.

Member Associations Involved in Ambulatory Care

The American Academy of Ambulatory Care Nursing (AAACN)The American Medical Informatics Association (AMIA)The Medical Group Management Association (MGMA)The Society for Ambulatory Care professionalsThe Federated Ambulatory Surgery Association (FASA)The American Association of Ambulatory Surgery Centers (AAASC)The Association for Ambulatory Behavioral HealthcareAmerican Health Information Management Association (AHIMA)(HIMSS) Healthcare Information Management Systems Society

Accreditation OrganizationAccrediting organizations validate standards of

practice and promote quality care.

1. Accreditation Association for Ambulatory Health Care (AAAHC)

2. COLA

3. The National Committee for Quality Assurance (NCQA)

4. The Joint Commission on Accreditation of Healthcare Organizations.

Journals and Conferences1. Journal of Ambulatory care Management- is a quarterly

publication. Each issue focuses on one topic of interest related to ambulatory care.

2. Ambulatory Pediatrics

3. The Journal for Healthcare Quality

Several conferences focus on information technology needs of the ambulatory care arena. One of the best known with the largest attendance:

1. MGMA Medical Group Management Association

2. AMIA The American Medical Informatics Association

3. TEPR

Future Directions for the Adoption of Information Technology in Ambulatory CareThe goals set by President Bush and the

appointment of Dr. David J. Brailer as the national coordinator will inject momentum into the adoption of automated systems into ambulatory care. There is a move to use computerized provider order entry (CPOE) systems in ambulatory care. The biggest area of impact is that of medication safety where it is thought that adverse drug events could be prevented.

Some ambulatory practices are using electronic mail, computer interviewing, voice recognition, handwriting, recognition, smart card technology, wireless devices, and biometrics.