The Omaha System.
The Omaha System is identified by nursingworld.org as “a comprehensive practice and documentation tool that can be used by multidisciplinary health care practitioners in any setting from the time of client admission to discharge. Omaha System includes an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes) “ (www.nursingworld.org). Within the Omaha System there are 4 levels of classification; starting with the most general category of domain and becoming more specific at each subsequent level through client problems, modifiers, and the most specific, signs & symptoms. The 4 Domains, at Level 1 of the classification scheme, are set up to give a picture of the whole client, including other factors that affect the client’s wellbeing; these domains are Environmental, Psychosocial, Physiological, and Health Related Behaviors. The 2nd Level of the classification scheme is Client Problems. These are the 40 nursing diagnoses that may cause harm to the client. They are all health-related matters that fall under nursing’s ability to diagnose and treat using nursing interventions. Examples include income, role change, respiration, or family planning. Each problem comes with a modifier from Level 3. Modifiers, Level 3 of the classification scheme, are always used with problems from Level 2. They include things such as health promotion, potential deficit/problem, and deficit/impairment/actual problem. Additionally, they identify whose problem this is, the individuals or the family’s problem. The Signs & Symptoms at Level 4 are the evidence that the problem exists, and are only used with the modifier actual from Level 3, and not with modifiers potential or health promotion. Whether the problem is with the individual or the family does not matter as long as the problem is identified as an actual problem. Signs & Symptoms are any evidence the problem exists that is observed by the nurse or any symptoms reported by the client. Examples include such things as limited social contact, flat affect, cyanosis, or hyperglycemia (Martin, K.S. & Scheet, N.J., 1992).
The Intervention Scheme within the Omaha system focuses on health restoration, preventing illness, or stabilizing/preventing illnesses from becoming worse. There are three parts to the intervention, the first consists of the four broad categories of interventions: Teaching, Guidance, and Counseling, Treatments and Procedures, Case Management, and Surveillance. The second part of the intervention consists of 75 targets or objects of action. The final part of the intervention involves providing client-specific information to the client. The teaching category focuses in on providing information and encouraging individuals to take responsibility for their self-care and coping. Treatments and Procedures focus on technical aspects of caring for clients, for example setting up/administering medications, range of motion exercises, wound care, etc. Case Management interventions include providing resources, referring and coordinating appointments or services, advocating for the patient, and promoting independence in appointment setting and other activities. Surveillance interventions include assessing and monitoring the individual or family situation/environment, and analyzing the factors that can influence individual/family health. Targets or objects of action at the second level include behavior modification, cast care, feeding procedures, ostomy care, or support group (http://www.omahasystem.org/shminter.htm
The Problem Rating Scale for Outcomes is a Likert-type scale that measures clients’/families Knowledge, Behavior, and Status. The scale is 1-5, 1 being no knowledge, not appropriate behavior, and extreme signs/symptoms. 5 indicates superior knowledge, consistently appropriate behavior, and no signs/symptoms. Each sub-scale is independent of one another; a person can have no knowledge (1 Knowledge), but consistently appropriate behavior (5 Behavior), and moderate signs/symptoms (3 Status). The scale is intended for use at regular intervals to monitor baseline and progress from baseline up until discharge or discontinuation of services (if applicable) (http://www.omahasystem.org/shmrate.htm
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The Omaha System was developed by The Visiting Nurses Association for use in the home care setting. The system was intended to diagnose, intervene/treat, and evaluate clients within the nursing scope of practice. Its focus was on the whole person and how other factors in that client’s life affect their health and wellbeing. Through the research and development phases of the Omaha System there was an attempt to make the terminology available to other practitioners, administrators, students, etc, and not just limited to nurses. As it was developed there was also an attempt to make the system applicable to a variety of disciplines, settings, and clients. The first to adopt the Omaha system on a more widespread basis were home care nursing and public health. There is currently research in a variety of different settings with a variety of different health care professionals and a variety of different clients (http://www.omahasystem.org/systemo.htm
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Potential Benefits in Clinical Practice.
There are several benefits of using the Omaha System in clinical practice. Two important components that the system brings to nurses in care settings are it’s usability and ability to organize data in a useful manner.
Usability is an important issue when deciding to implement a vocabulary system into a practice setting. A study by Bowles found that the placement of diagnosis and interventions into the system is intuitive for practicing nurses (2000). The labels are common healthcare terms and require little to no definition, even though there is a handbook to clarify any ambiguous vocabulary. Also, the size of the system makes it thorough, yet very manageable.
Apart from usability in practice, the Omaha system makes analyzing gathered data possible. The system has a guiding framework that systematically tracks problems, goals, interventions, and patient response. The format in which the data is collected facilitates simple analysis at a population level. That data can be used to better understand a population’s need for services or modifications of interventions. Data can also be compared across populations nationally or globally (Erci, 2005).
Usability in a variety of different health care settings and by a variety of different health care professionals is an additional advantage in clinical practice. The ability of a nurse to chart in the same system as case management and physical therapy using the same terminology enhances flow of work and understanding among disciplines (Westra, B. & Solomon, D. 1999).
-- Main.blac0215 - 11 Jul 2007
Early in the 1970's the Omaha Visiting Nurse’s Association (VNA) started development of a clinical database capable with the aim of being included in a fully integrated, automated management information system. The result became known as the Omaha System. Publicly funded from it’s inception this system has been without copyright, existing in the public domain and remaining accessible to all health care disciplines. The Omaha System was one of the earliest taxonomies recognized by the American Nurses Association, in 1976.
Work on the Omaha System initiated when the staff of the VNA of Omaha began revising their client records to adopt a problem-oriented approach. An empirical, inductive approach was used throughout the research projects by collecting actual client data from several sites around the U.S. This data was then aggregated, analyzed and submitted for inclusion into the system. Between 1975 and 1986 research projects funded by the U.S. Division of Nursing: Department of Health and Human Services further contributed to the development and redefinition of the system. Further tests were conducted between 1989 and 1993 on the reliability, validity, and usability of the system. The first book was published in 1992 (www.omahasystem.org).
A network of practitioners employed by the VNA of Omaha and practitioners located at seven test sites throughout the US all submitted their collected data to be included in the Omaha System. Additional participants were also given a voice in the development, including advisory committee members and consultants (www.omahasystem.org).
When the Omaha System was first introduced it was designed for nurses in community and public health services but has now been adopted for use in other clinical practice sites. The VNA of Omaha recently conducted its fourth testing, funded by the National Center for Nursing Research, of the Omaha System in which reliability, validity, utility, and generalization potential were again intensely examined. In 2005 another book was published based on continued research and expansion into other domains of nursing and health care practice.
- 10 Jul 2007
Use of the vocabulary today.
From Turkey to Holland to China and even the great state of Iowa the Omaha System is used extensively in practice, education and research throughout healthcare today. Martin (2005) identifies 169 user organizations and their 8000 employees who are located in 14 countries. He goes on to suggest that the type and location of users has expanded dramatically. Commercial use of the Omaha System is increasing rapidly with the use of electronic health records. Users of the system range from home care, schools, and public health. Several studies have been conducted in the acute care settings and work is being down to identify what improvements may be made to bring the information system into hospital-based settings. The web site www.omahasystem.org sites users ranging from hospital based managers to occupational health, in addition to parish nurses and nursing educators to name a few. The patient populations range from acute care settings to long-term care.
As described earlier in this document the Omaha System is used by multidisciplinary health care practitioners in any setting but has been found to be most valuable in the community and home care settings.
The Omaha System was one of the first taxonomies or terminologies recognized by the American Nurses Association. The Omaha System is congruent with the reference terminology model for the International Organization for Standardization, and the accreditation standards of the JCAHO and Community Health Accreditation Program. It is included in the National Library of Medicine’s Metathesaurus, SNOMED CT®, the ANSI HISB Inventory of Clinical Information standards, Alternative Link, and the Alliance Standards Directory. It is indexed in CINAHL®, registered (recognized) by HL7, and integrated into LOINC (www.omahasystem.org)
An example of the use of the Omaha System in the public health arena comes from the Marion County Health Department (MCHD) in Indianapolis, IN. Nursing leaders identified a need to move away from paper charting. “We wanted to standardize the language used in the charting process, so that it would be clear and concise,” said Donna Daulton, RN, public health nurse with the MCHD. Beginning in 1997 consultant familiar with the Omaha System was hired. The decision was made to use a software package based on the taxonomy of the Omaha System. Recognizing the importance of HIPPA, patient privacy and accuracy in documentation became even more important reasons for having a clear and concise way of recording client care. The Omaha System was recognized to have a focus on client outcomes, as it contains a Likert-type rating scale. This feature parallels the Healthy People 2010 Objectives. In 2003 ongoing training and developing a broader use for the Omaha System was being conducted.
More recently, an article published in the journal of Home Care Management & Practice (2004) cited the need for advanced practice nurses working in a wellness center for the elderly to be able to measure and quantify the outcomes of care. The article titled “The Alternatives for Wellness Centers: Drown or Develop a Reasonable Electronic Documentation System” captured the sense of most nurses that of “drowning” in paper charting. Using the Omaha System the wellness center was able to collect and manage both qualitative and quantitative data. Lessons learned from their experience and advice given to those who are considering implementation of an information system is the need to systematically evaluate the data and information needs of their patient population as well as critical review of available information systems.
Usefulness According to the Literature.
The Omaha system has been studied and deemed valuable for working in the community and home care settings. Research shows the system has enabled nurses to more readily describe patients’ needs and what actions the nurse takes in patient care. Concerns have been expressed about the ability to use the OMAHA system in an acute care setting which it was not originally designed for. A large study shows that with some modifications, the vocabulary could be easily introduced to inpatient care settings.
Erci’s 2005 study of the usefulness of the OMAHA system was performed with families in a community health system. The study proved the vocabulary for the problems and interventions to be accurate when describing the patient population. The study also favored the OMAHA system because the main focus of many of the goals is on patient education. For example, if you teach someone about finding affordable housing, a goal of having a home is not met. However, they have successfully met a goal that is focused on increasing knowledge. In the outpatient setting, education and increasing client knowledge is a more frequent intervention than a more physiological problem such as difficulty breathing.
It has been accepted that the OMAHA system is a great tool for home care; but, as we approach universalized EHR, can the language be translated into an acute care setting? A 2000 study by Bowles reveals that while there is much strength to the system, there are a few weaknesses that need to be addressed before implementation will be possible. In the mentioned study, nurses on a unit were given the OMAHA system to work with and empirical, operational, and pragmatic utility were tested. The researcher found that the system had high reliability, coded 97% of the problems, and was very easy to use. The limitations included lack of mutual exclusivity, lack of semantic clarity, and need for 3 new problems. Mutual exclusivity was absent when the nurses were documenting targets. For example, I&O could fall under physical signs/symptoms and nutrition. This was found to be a problem for standardization. The nurses in the study also found some of the definitions to be unclear, causing more need for semantic clarity. In addition, a need for three problems that are not currently part of the OMAHA system were discovered- fever of unknown origin, problems related to the healthcare environment, and discharge planning. With the modification of these problems, the system could be implemented into the acute healthcare setting and therefore be used in the EMR.
Westra also preformed a study to see the system could technically be created as a computer medical record program. This was successful with CareFacts?
Clinical Information Systems and a computerized charting system was created (Westra and Solomon, 1999). Because the OMAHA system puts data into a very useable format that is easily analyzed, the programs will be very useful when needing to make comparisons.
The literature shows that the OMAHA system provides use with a vocabulary that is useful in home and community settings, can be modified to be useful in acute care settings, and can be implanted into a computerized charting system.
-- Main.blac0215 - 10 Jul 2007
The philosophy of the Omaha System is for it to be as brief and flexible as possible, to be used by nurses and other disciplines in various settings, and to be simple in structure. The developers of the system intentionally created it this way and view it as one of the primary strengths of the system (Martin 2006). The Omaha system portrays a more holistic view of the patient as it has the ability to link clinical data to financial, administrative, demographic, and staffing data. Thus, “implementing the Omaha system can produce a vivid portrait of client needs, the health care services provided, and the outcomes of service” (www.omahasystem.org).
The Omaha system includes all three aspects of care—diagnoses, interventions, and outcomes. Several other terminologies also integrate these three important concepts together, such as CCC, ICNP, and PNDS. Other terminologies exist such as NIC and NOC, which focus on only one concept and must be paired with other terminologies.
The Omaha system has been in existence longer than many of the other terminologies and therefore longevity and widespread use of the system are also strengths. A 2005 study reported that approximately 75% of home care and public health care organizations used the Omaha systems for their documentation (www.omahasystem.org). It is also used internationally, having already been translated into Danish, Dutch, Chinese, Japanese, Swedish, and other languages (www.nursingworld.org). The Omaha system is not copywrited and therefore equally accessible to all users (Martin 2006). The Omaha system is integrated into LOINC and SNOMED CT, and it is incorporated in the UMLS Metathesaurus as well as the accreditation requirements of JCAHO and CHAP. The Omaha system is registered by HL7, and it is included in indexes such as CINDAHL (www.omahasystem.org)
The Omaha system has a method of maintenance and continued development system that is based on research and user feedback. So when revising the system the authors take both the research as well as information gathered from nurses via surveys into account to enhance the system (www.omahasystem.org). As we move closer to the implementation of a interoperable EHR, the strengths of the Omaha system cannot be ignored. As it cited in the literature reviewed in this summary, the Omaha system has proven to be an information system that is effective and able to foster coordination of patient care.
The major weakness of the Omaha system as compared to other terminologies such as ICNP, NANDA, and NOC is that the Omaha system was developed in the home care, public health, and community setting as opposed to the hospital setting in which many other terminologies were developed. Thus, currently, the Omaha system is not as comprehensive as needed in the acute care setting (Bowles, 2000). Bowles (2000) identified the need for 3 new problems as an obstacle for implementation of the Omaha System into acute care settings. Due to the Omaha System being developed in the home, there is currently no category recognizing the impact of the hospital environment (roommate, routine, etc), no category for documenting discharge planning specifically, and no way to document fever of unknown origin, which is frequently used and needed in the inpatient setting.
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Future implications for practice, education, and research.
The Omaha system is widely accepted and used within the nursing community, is comprehensive in its scope, and is oriented toward the holistic view of the patient, thus it is poised to grow along with the practice of nursing in the future. A study in the American Journal of Public Health reported that the Omaha system was useful in “describing and quantifying nursing practice in the community health setting (Martin, Sheet, Stegman; 1993).” The data collected and documented while using the Omaha system represented vital characteristics of home health care clients in a large national sample. Since the Omaha system was originally designed for use in the home care, public health, and community setting, there is now the opportunity to adapt the Omaha system for use in the acute care setting. A study in Research in Nursing and Health used the Omaha system to code the terms used by nurses in the hospital setting, and their findings suggested that the Omaha system has important implications for future adaptation to the acute care setting (Bowles, 2000). Several strengths were identified, such as high reliability and ease of use, and some limitations were also noted, such as the need for additional problems. With proper adaptation, the Omaha system shows great promise for expansion into the acute care setting.
In addition, the Omaha system is poised to become even more interoperable with other systems currently in use in the healthcare setting. The Omaha system is currently mapped with several other systems, including LOINC and SNOMED, and has the capability to be interoperable with a vast array of additional systems in the future.
The Omaha system is by nature a research-based system, as it was developed and refined through a series of research projects spanning from 1975 to 1993. These research projects were funded by the Division of Nursing and the National Institute of Nursing Research. The revisions seen in the 2005 version of the Omaha system are the direct result of extensive research into the use and applications of the system. Research evaluating the Omaha system will continue to be performed in the future as new versions of the system are created and as the Omaha system is mapped with other systems and/or adapted for use in the acute care setting (www.omahasystem.org/systemo.htm).
The Omaha system has been used by educators since its inception. The 2005 version of the Omaha system guidebook notes that there are 169 user organizations and 8000 employees located in 14 countries, and these users range from healthcare professionals to researchers to educators (www.omahasystem.org/systemo.htm). Educators will continue to use this system as it is revised and adapted in the future. The other aspect of education vital to the Omaha system is adequate learning opportunities for employees new to the system. This will be especially important as new versions and adaptations of the systems are released. One study suggested that emphasizing education on the use of the Omaha system would improve the staff’s understanding of the program during its implementation (http://eaa-knowledge.com/ojni/ni/dm/omahaart.htm
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