Not for Nurses Only.

A NIDSEC Primer.

Remember the song about the ant and the rubber tree plant? Well, I feel a lot like that ant as I attempt to summarize NIDSEC in about 1,000 words. While this will require some rather arbitrary decision-making, which undoubtedly will lead to criticism, I remain, like the ant, determined in the face of an impossible task.

The American Nurses' Association established NIDSEC, the Nursing Information and Data Set Evaluation Center, to establish criteria for rating the extent to which information systems support nursing practice documentation. NIDSEC established standards and a Likert-type scale for rating systems in each of four dimensions: nomenclature, clinical content, clinical data repository and general systems characteristics. NIDSEC's purpose is to expedite the evolution of large, accessible pools of information including data about nursing care, thus reflecting the true nature and costs of total patient care.

Because of the widespread disparity in the terms used by computer-based information sources, the National Library of Medicine (NLM) developed the Unified Medical Language System (UMLS) to incorporate and translate a wide variety of healthcare vocabularies to enable pooling and transferring of data across sites/settings of care.

Nomenclature ... refers to the terms used to document the planning and delivery of nursing care, stored in a system's data dictionaries. To reflect the nursing component of patient care,

1. "The data set uses an American Nurses' Association (ANA) recognized nomenclature(s) or terms ... from the NLM's Unified Medical Language System.... Terms in the data set are identified with unique codes, and there are safeguards to prevent duplication."

This standard helps assure that data are collected in the same way, thus simplifying sharing, transferring and pooling of patient information. The UMLS includes the following nomenclatures:

* For Nursing Diagnosis: The North American Nursing Diagnosis Association's (NANDA) approved list of nursing diagnoses. There are other nursing diagnostic systems besides NANDA, but this is the one most wisely used and recognized. The Omaha System, and Georgetown University's Home Health Care Classification (HHCC);

* For Nursing Interventions: The University of Iowa's Nursing Intervention Classification (NIC), The Omaha System, and HHCC;

* For Nursing Outcomes: The Nursing Minimum Data Set (NMDS), the Omaha System, and HHCC.

* Other Approved Systems: Please visit www.ana.org/nidsec to view a complete listing of ANA approved nomenclatures.

2. "System data dictionaries ... include structured terminology to document all phases of the nursing process."

This standard, while extremely sensible, is more difficult to implement because the approved nursing languages have varying structural elements. Thus, to minimize error, when a system uses a standard nomenclature, it should use it in its entirety. Moreover, not all the languages encompass all the phases of the nursing process. Only the Omaha System and HHCC cover diagnosis/problems, interventions and outcomes.

3. "The data set allows for the addition of new, unique terms."

4. "The system provides for a unique identifier for each nurse provider."

Clinical Content ... refers to the options data entry systems display for recording assessments, diagnoses, interventions and outcomes. When a pathway branches in response to choices made on previous screens, are the options displayed complete, accurate and clinically appropriate? NIDSEC's key evaluation factors include the following:

1. "The system provides branching pathways that make associations from: (a) assessments to diagnoses; (b) diagnoses to expected outcomes; (c) diagnoses to interventions planned; (d) interventions planned to interventions delivered; and (e) expected outcomes to actual outcomes."

Predetermined pathways can support complete, appropriate and accurate clinical decision-making and efficient documentation, or undermine it. The term complete refers to all the expected choices in a pathway (e.g. signs and symptoms can be recorded when using the Omaha System). The term appropriate means the choices reflect both the nomenclature's structure and the clinical setting or patient population. The term accurate means there are no errors of omission or commission in the choices displayed.

2. "The system allows users to record all actions prescribed by the plan of care, including progress notes, flow sheets, critical paths.... Information about care delivered is associated with information about care planned, and both are stored permanently in the patient's integrated health record."

Systems that maintain this association allow evaluation of clinical decision-making and the process and outcome of care delivery.

Clinical Data Repository (CDR) ... often called an information storehouse, it allows for the efficient retrieval of a compendium of patient health/care data. The CDR stores data longitudinally over multiple episodes of care and, ideally, in multiple forms, from text to images. NIDSEC's key evaluation factors for a CDR include:

1. "The system permanently stores patient-specific data in electronic form in an accepted (e.g. ANSI) standard database format and allows the data to be exported to standard databases."

To this end, the system should provide good documentation of the file structures, schema, and coding of items stored as well as the ability to export data to facilitate access, retrieval and analysis for clinical and research purposes.

2. "Patient-specific data elements are stored in coded format, using recognized coding schemes."

Data stored in linear strings of text are almost impossible to retrieve and manipulate. Storing data in a coded format makes it more amenable to automated retrieval, aggregation and analysis--and the coding schemes should be consistent with UMLS so data can be pooled over cooperating agencies.

3. "All clinical data elements specified in the Nursing Minimum Data Set (NMDS) and related nursing data are stored permanently in the CDR."

The NMDS consists of the nursing diagnosis, nursing interventions and nursing outcomes. If the CDR stores only an abstract of the patient record, the system should retain links from the abstracted data to the full database.

4. "The System retains the CDR associations made during data entry, thus data retrieval reflects clinical decision-making processes."

General Systems Characteristics ... refers to the hardware/ software required to support the CDR. Key evaluation criteria include:

1. "The vendor supplies formula(s) for computing hardware requirements needed to meet CDR provisions, given an estimated data volume."

While rapidly advancing technology is making data storage ever more capacious, it must be recognized that most hospitals and health systems do not have the latest technology. With millions upon millions of dollars invested in what they do have, they still need compatible systems. This being said, if an organization does not have enough information to estimate its data storage needs, and data are purged because of insufficient storage, it will be impossible to accumulate a database of nursing related information--and thus, at best, both the clinical and financial picture will be incomplete. Organizations need to deal with vendors who can and do supply the formulae needed to make reasonably accurate predictions of current and future data storage needs.

2. "The vendor supplies formula(s) for computing hardware requirements needed to meet processing requirements of the CDR, given an estimated transaction volume."

The primary reason for having a structured, coded CDR is data retrieval. Without sufficient processing capacity, data retrieval is cumbersome at best, crippling at worst.

How's that for a quick primer? Whoever said an ant can't move a rubber tree plant?

To obtain more information about NIDSEC standards and evaluation, go to www.ana.org and type NIDSEC into the search field.

Leah Curtin, RN, ScD(h), FAAN, is editor-in-chief of CurtinCalls, an irreverent, fact-filled scan of nursing and healthcare, Cincinnati, OH. Roy L. Simpson, RN, FNAP, FAAN, is vice president of Cerner Corp., Kansas City, MO.