Research and Theory for Nursing Practice: An ...

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Research and Theory for

NURSING PRACTICE An International Journal

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Research and Theory for Nursing Practice: An International Journal, Vol. 30, No. 3, 2016

Empirical Evaluation of International Health System Data Interoperability: Mapping the Wanda Horta Theory to the Omaha System Ontology Lisiane Pruinelli, MSN, RN University of Minnesota

Amalia de F. Lucena, PhD, RN Hospital de Clinicas of Porto Alegre, Federal University of Rio Grande do Sul, Brazil

Karen A. Monsen, PhD, RN, FAAN University of Minnesota

Structured health care data has played a critical role in improving quality of care and achieving better patient outcomes. Despite increased use of terminology standards within the electronic health records (EHRs), there is a need to map multi-institutional data that represent patient observations to develop standardized information models. The purpose of this study was to conduct an empirical evaluation of the potential for international health system data interoperability with the Wanda Horta theory using the Omaha System ontology. The 2 frameworks were mapped and validated by a panel of experts. The results showed that the majority (80.95%) of the Wanda Horta theory concepts were mapped at a high level of agreement. Such mappings show that the information models have the potential to facilitate and enhance communication and improve practices between organizations internationally.

Keywords: standardized terminologies; Omaha System; nursing informatics; electronic health records; nursing data

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lobally, the implementation and use of electronic health records (EHRs) has been advanced toward the goal of achieving better patient outcomes. Information models have played a critical role because they underlie the structured tools that improve quality of care as well as facilitate clinical decision

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support in practice (Anderson, 2009; Anderson, Halley, & Sensmeier, 2011). Nurses in particular have reported advantages of using structured tools, such as interface terminologies, that result in quicker and more efficient documentation; data for real-time decision making; and documentation clarity that increases patient safety, permits uniform language, and enhances communication (Anderson, 2009; Anderson et al., 2011). Nursing records based on information models have been implemented internationally, and studies have shown positive results that support standards of care and practice (Abdrbo, Hudak, Anthony, & Douglas, 2011; Alvarez & Dal Sasso, 2011; Anderson et al., 2011). Although the use of standardized terminologies in nursing documentation has increased worldwide, information models differ across national boundaries, and interoperability across these settings has been a challenge (Alexander & Staggers, 2009). Specific challenges have been identified in using these standards to exchange nursing knowledge and population health data to build better evidence for practices that can be shared and reused (Alvarez & Dal Sasso, 2011; Anderson, 2011; Barra & Dal Sasso, 2010; The 2009 nursing I.T. innovation awards, 2009). However, there is lack of agreement about standards across institutions on how nurses document patient health data. If standardization exists, multi-institutional data could be combined for research purposes with the goal of improving clinical practice and achieve better quality of care. One method for addressing this gap is to map different nursing data adopted in different care settings and analyze how these data assess the same health phenomenon. The purpose of this study is to determine if it is possible to cross-map the Wanda Horta (Anderson, Hassett, & Sensmeier, 2010) theory, a Brazilian model, and the Omaha System (Anderson & Sensmeier, 2011; Martin, 2005), an international interdisciplinary ontology. If the two frameworks could be cross-mapped, it would be the first step in comparing nursing assessments based on them, and consequently, in sharing nursing data as population health variables across Brazil and other countries. The similarities between the holistic theoretical structure of the Wanda Horta theory and the Omaha System ontology provided the rationale and basis for this cross-mapping. A limitation of the Wanda Horta theory is that it is difficult to compare internationally because it is uniquely used and recognized inside Brazil. Furthermore, the Wanda Horta theory is published only in Portuguese, and few bibliographies using it as a reference are available in international literature. On the other hand, Wanda Horta theory drives nursing knowledge in Brazil and has been used as the foundation for research in that country, as well as the methodologic framework for studies that associate Brazilian nursing care with international terminologies (de Fátima Lucena, Holsbach, Pruinelli, & Cardoso, 2013; Luzia, Almeida, & Lucena, 2014). However, up to date, no mapping was developed with the specific aim of to evaluate the potential for international health system data interoperability. To further use Brazilian nursing data in international research and be able to compare findings across institutions and countries, the Omaha System may provide a bridge for using the Wanda Horta theory and its methodology internationally. Omaha System was chosen because it is an adopted and recognized international ontology and shares several theoretical similarities with the Wanda Horta theory.


Empirical Evaluation of International System Data Interoperability231

WANDA HORTA THEORY Wanda Horta, a Brazilian nursing theorist, based her work on Maslow’s human motivation theory and in the classification of Mohana’s necessities, which is divided into three hierarchical levels (Anderson et al., 2010): (a) Psychobiological: oxygenation, hydration, nutrition, output, sleep and rest, exercise and physical activity, sexuality, shelter, body mechanics, motility, personal care, mucosa skin integrity, physical integrity, regulation (temperature, hormonal, neurological, hydrosaline, electrolyte, immunological, cell growth, and vascular), mobility, perception (olfactory, visual, auditory, tactile, gustatory, and painful), environment, and therapy; (b) Psychosocial: security, love, freedom, communication, creativity, learning (health education), sociable, recreation, leisure, community, time and space orientation, acceptance, self-realization, self-esteem, participation, self-image, and vigilance; and (c) Psychospiritual: religious or theological, ethics, and philosophy of life. According to Horta, the nursing process is the dynamics of systematized actions and is interrelated to the care of human beings, organized into six steps (Anderson et al., 2010). First, the assessment or nursing history includes the systematic strategy for data collection. Second, the nursing diagnosis identifies the needs of the human being. Third, the care plan is based on the nursing diagnosis. Fourth, the prescription of nursing care where the care plan is implemented, using a daily strategy with items signed once for each action at the time that is provided. Fifth, the nursing notes include daily reports of the state of the human being, with descriptions of the changes observed by the nurse in response to the care implemented. Finally, the nursing prognosis is provided with an estimated capacity of the human being to have their needs changed after implementation of nursing care. This model has been used in Brazil since the 1970s, although not in its totality. Some of these steps, such as the nursing diagnosis and nursing prognosis, were not sufficiently developed for successful application in clinical practice. However, the knowledge acquired about the nursing process proposed by this model created a basis for the organization of nursing care and the qualification of nursing records inside EHRs across the country. One Brazilian example, as a precursor to using the Horta theory in the nursing process, is provided by the Hospital de Clinicas of Porto Alegre (HCPA), Federal University of Rio Grande do Sul, Brazil. At this institution, the nursing documentation has been integrated within the patient health record for outpatient clinics since its foundation in 1970 and for inpatient clinics since 1972. The Horta theory provided the framework on which the nursing process was continuously studied, structured, and implemented as an assessment and documentation tool using the following steps: assessment, nursing problems, nursing care prescription, and nursing evaluation (Anderson et al., 2011). In particular, the assessment tool follows the Wanda Horta theory solely. However, the nursing assessment did not include all aspects of the Horta theory. For example, the concepts of freedom and participation were not incorporated within the psychosocial needs assessment. However, this assessment tool represents the foremost


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approach for collecting patient data where patient and family needs are assessed by nurses, taking into account the patient as a whole human being (Bissonnette, 2009). In addition, the specific information received from specialized departments was adapted by customizing the assessment tool for psychiatry, maternal care and delivery, cardiology, and pediatrics. The HCPA EHRs were implemented in 2000, and the assessment tool was added to the EHR in response to the increased demand for better nursing practices. Later, some efforts were made to incorporate additional terminologies, such as North American Nursing Diagnosis Association International (NANDA-I; Bickford, 2009), and to nominate nursing diagnoses instead of using nursing problem lists. The Nursing Interventions Classification (NIC; Bembridge, Levett-Jones, & Jeong, 2010) was incorporated with the aim of describing the nursing care actions prescribed. Recently, the Nursing Outcomes Classification (NOC; Bichel-Findlay, Callen, & Sara, 2009) was integrated as a strategy for measuring nursing care results. These terminologies were implemented as care plan aids and were associated with the needs assessment tool developed from the Wanda Horta theory. The National Program for Restructuring Federal University Hospitals (AGHU) is managed by the Ministry of Education, which has among its objectives the implementation of new health technologies to support its incorporation into the Brazilian Unified Health System. Although Brazil has already a single universal health system in place, the quality of care varies greatly across the country as well as has found difficulty in managing cost of care and other administrative issues because of the lack of standard procedures. The AGHU was created to address these difficulties, that is, to decrease the inequality of care and increase cost-effectiveness through the adoption of a more centralized and computerized management tool. Currently, HCPA is the hospital model for this program in which the government intends to insert the computerized system module from HCPA into 55 federal university hospitals. Besides the electronic system that comprises the information exchange from admission to discharge of patients and management support tools, this module is also composed of the nursing prescription and the theoretical framework based on the Horta theory. Between 2013 and 2014, this module was implemented in seven hospitals in different regions of the country. It is assumed that in the near future, other hospitals will adhere to this model, which will enable a uniform nursing language and therefore allow multicentric research to be conducted for advanced nursing informatics knowledge.

OMAHA SYSTEM Another multidisciplinary standardized terminology, the Omaha System, is a knowledge model, or ontology, for health care that supports nursing practices (Martin, 2005). It meets the U.S. Department of Health and Human Services interoperability standards for EHRs (Anderson & Sensmeier, 2009). In addition, it is integrated into the National Library of Medicine’s Metathesaurus, Cumulative Index for Nursing and Allied Health Literature; Alternative Billing Concepts Codes; Nursing Information and Data Set


Empirical Evaluation of International System Data Interoperability233 Evaluation Center; Logical Observation Identifiers, Names, and Codes (LOINC); and Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT). Moreover, it is recognized by Health Level Seven (HL7) as a terminology capable of data capture and exchange which meets the data standards criteria for Meaningful Use (Anderson & Sensmeier, 2009). It was developed through extensive studies that documented validity, reliability, and usability as a robust instrument for clinical documentation (Bello, Quinn, & Horrell, 2011). It is composed of three components: the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes (Anderson & Sensmeier, 2011). The Problem Classification Scheme is then organized into domains and each domain into problems, modifiers, and signs/ symptoms. Each problem statement has multiple parts that flow from general to specific information. Four domains (Environmental, Psychosocial, Physiological, and Health-related Behaviors) represent client health-related concerns which are referred to using 42 terms describing client problems; foci; nursing diagnoses; and areas of clients’ needs, concerns, and strengths (Anderson & Sensmeier, 2011). Many studies have addressed the Problem Classification Scheme, which is currently widely in use in public health settings, as well as a health care ontology used as a conceptual framework for health (Anderson, 2009; Bakken et al., 2009; Baldwin, 2011). It has been shown to represent inpatient nursing concepts and thus may facilitate interoperability across inpatient and outpatient settings (Monsen, Schenk, Schleyer, & Schiavenato, 2015).

PURPOSE The aim of this study is to evaluate the feasibility of mapping the Wanda Horta theory to the Omaha System ontology. The study had three aims: (a) to conceptually map the Wanda Horta theory and the Omaha System, (b) to map assessment tools derived from the Wanda Horta theory and the Omaha System, and (c) to clinically validate the cross-mapping of assessment tools using clinical EHR data in a confirmatory analysis.

METHODS After approval by the Institutional Review Board (IRB), a cross-theoretical mapping of content and semantic validation was conducted by an international panel of experts. This methodological approach has been used as the primary choice for encoding and comparing different and/or unstructured languages (Barrett, 2009; Barton, 2010). The expert panel was composed of one expert in the Omaha System with English as the first language (KM); one expert in Wanda Horta theory with English knowledge and Portuguese as the first language (AFL); and a graduate nursing student who had worked with and has theoretical knowledge of the Wanda Horta theory and the Omaha System, with Portuguese as the first language but with English proficiency (LP).


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Psychospiritual

Physiological Omaha System Psychosocial Psychobiological

Horta Psychosocial Health-related Behaviors Environmental

Figure 1. Conceptual mapping of the Omaha System and Wanda Horta theory. Dark grey circles are from the Wanda Horta theory and light grey circles are from the Omaha System.

For Aim 1, the domains of the Wanda Horta theory were mapped conceptually by the authors using a Venn diagram (Figure 1). For Aim 2, the assessment items of the adult general assessment tool based on the Wanda Horta theory were translated and mapped onto Omaha System problem concepts. The adult general assessment tool used in this study was based on the Wanda Horta theory and was translated into English by one of the investigators (LP) and reviewed by another (AFL). It was decided by the research team not to include the customizations in this study because the adult general tool is the most frequently used and covers most patients. LP matched the assessment tool with the Omaha System Problem Classification Scheme using a Microsoft (MS) Excel spreadsheet. The Omaha System problems and the Horta theory assessment necessities were matched, and the level of correspondence was classified as exact, high, partial, or no match. An exact or high-match classification was given when both systems had exactly the same meaning; a partial match covered at least 50% of the content, and a no exact match was given when there was no agreement on any level between both systems. The investigator used a description of each item to find the level of correspondence: not merely if the name had the same meaning in both systems, but if they truly intended to measure the same concept. Following this first step, KM and AFL validated those findings, taking into account cultural knowledge and expertise with those systems. Descriptive statistics were used for analysis of the theoretical cross-mapping.


Empirical Evaluation of International System Data Interoperability235 For Aim 3, to empirically evaluate the cross-mapping and further identify relevant information that could be missed during the first step, clinical de-identified Wanda Horta theory-based assessment data from the EHR was matched with the expert panel results. Two randomly selected completed assessment tools from adult patients admitted to the general surgery units were included in this study. The sampling selection was randomly performed by one of the investigators (AFL) through the Brazilian hospital EHR system, all personal health-identifying data were removed, and the sample was translated from Portuguese to English by LP. AFL reviewed the translated documents to detect additional language or cultural misinterpretation. The clinical data sample was then mapped to the previous cross-map by LP and validated by KM and AFL. Descriptive statistics were used for the confirmatory analysis.

RESULTS Aim 1: Figure 1 shows the mapping between the four distinct domains of the Omaha System Problem Classification Scheme and the three distinct necessities from the Wanda Horta theory. Theoretically, the Physiological and Psychosocial necessities from the Wanda Horta theory corresponded closely with the Physiological and Psychosocial domains from the Omaha System, respectively. The Omaha System Health-related Behaviors domain was mapped between the Psychobiological and the Psychosocial necessities from the Horta theory. The Horta theory Psychospiritual necessity was mapped within the Omaha System Psychosocial domain. The Omaha System Environmental domain was mapped partially within the Horta theory Psychosocial domain. Aim 2: Content and semantic evaluation showed that of 42 concepts from the Problem Classification Scheme of the Omaha System, 80.95% of the items from the assessment tool met an exact/high or partial level of correspondence (Table 1). It is important to note, however, that specific nursing specialties have customized the assessment tool, and incorporating these additional customizations would have increased the level of correspondence by 9.5%. Aim 3: Confirmatory analysis was performed through clinical validation for identifying whether the nursing assessment was congruent with the assessment tool. At this point, items that met partial and high/exact level of agreement were combined for data analysis. Analysis of de-identified Horta theory assessment tool data showed that 74.9% of the Omaha System items were assessed by the nurse during inpatient assessment, which represents 6.05% fewer than the expert validation results. Items that did not match in either analysis were grief, family planning, postpartum, pregnancy, caretaking/parenting, and neglect. These results show that almost all the items listed in the assessment tool are assessed by nurses during patient evaluation. Furthermore, there was an 80% correspondence between the clinical data from the Psychobiological hierarchy from the Wanda Horta theory and the Physiological domain in the Omaha System. Figure 2 displays the agreement level across the expert validation process and the confirmatory clinical data analysis according to the different domains from the Problem Classification Scheme.


Patient Needs

Problems

Housing Lifestyle and work Companion, coming from family relationship Psychospiritual needs Impact of disease on personal life Family relationship Beliefs, values

Residence

Neighborhood/workplace safety

Communication with community resources

Social contact

Role change

Interpersonal relationship

Spirituality


x

x

x

No Match

Neglect

x

x

x

x

x

x

x

Partial

x

Preventive exams, sexual activity/ sex life, method of protection against STDs

Sexuality

x

x

x

Exact/High

Expert Validation

Caretaking/parenting

Impact of disease on personal life

Mental health

Grief

Environmental conditions

Sanitation

Income

Assessment Tool/Wanda Horta Theory

Omaha System

Level of Correspondence

0

0

2

2

0

2

2

2

2

2

2

2

1

0

Case 1

0

0

0

2

0

2

0

2

2

2

2

2

1

0

Case 2

Clinical Validation

TABLE 1. Problem Classification Scheme Items and Assessment Tool Items With Corresponding Results Used During the Validation Process

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Customization Hearing Vision Communication Physical examination of the oral cavity

Growth and development

Hearing

Vision

Speech and language

Oral health Orientation Pain Level of consciousness Skin, Braden Scale Mobility, sensation, functional assessment, fall risk assessment (Morse) Respiration, physical examination of the chest Tax, BP, HR, peripheral perfusion pulse, physical examination of the extremities Food/fluid intake, weight change, weight and height measurement Intestinal Urinary

Cognition

Pain

Consciousness

Skin

Neuromusculoskeletal function

Respiration

Circulation

Digestion-hydration

Bowel function

Urinary function

a

History of home violence

Abuse


x

x

2

2

2

2

x

x

2

x

2

x

2

2

2

2

2

2

2

2

2

x

0

x

x

x

x

x

x

x

x

x

(Continued)

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

0



Customizationa Customizationa Preventive exams, methods of prevention against sexual disease Food/fluid intake Sleep and rest habits Physical activity Conditions of hygiene Alcohol, smoking, other drugs Customizationa Education limitation Medication

Reproductive function

Pregnancy

Postpartum

Communicable/infectious condition

Nutrition

Sleep and rest patterns

Physical activity

Personal care

Substance use

Family planning

Health care supervision

Medication regimen

x

x

x

x

x

x

x

x

Exact/High

x

Partial

x

x

x

No Match

Expert Validation

2

2

0

2

2

2

2

2

0

0

0

2

Case 1

2

2

0

2

2

2

2

2

0

0

0

0

Case 2

Clinical Validation

Note. Scores used during clinical validation: 0 5 no match, 1 5 partial match, 2 5 high/exact match. STD 5 sexually transmitted disease; BP 5 blood pressure; HR 5 heart rate. a Items that have customizations across various specific populations inside the hospital and were not included in this process.

Patient Needs Physical examination of the breast and genitals

Problems

Assessment Tool/Wanda Horta Theory

Omaha System

Level of Correspondence

TABLE 1. Problem Classification Scheme Items and Assessment Tool Items With Corresponding Results Used During the Validation Process (Continued)

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Level of agreement (%)


100 90 80 70 60 50 40 30 20 10 0

Expert Clinical Environmental domain

Psychosocial domain

Physiological domain

Health-related Behaviors domain

Problem Classification Scheme—Omaha System

Figure 2. Level of agreement between expert consensus and clinical data for the cross-map between the Wanda Horta theory needs assessment and the Omaha System Problem Classification Scheme.

DISCUSSION This study mapped two holistic health care frameworks. It is a first step toward establishing comparable population data derived from tools from the two frameworks. The results demonstrate that it may be possible to use the Omaha System as a valid framework to compare structured assessment data from Brazil and other countries. This study also emphasizes that differences exist in terminologies, theories, and tools adopted by nurses worldwide and that in spite of this, it is possible to compare data and nursing documentation across settings using languages that are similar and have a common reference point, such as the Omaha System. Studies have reported that there are discrepancies between what evidence-based practice guidelines recommend and clinical implementation and that it could be challenging to use those guidelines to support documentation quality (Bello et al., 2011). On the other hand, our study found only a small difference between the expert and clinical validation, which demonstrates a high level of accordance between what is recommended by the assessment tool and what the nurses actually do. The conformability may be associated with higher documentation quality, which may be a result of the nursing trajectory in that institution where the nursing process has been comprehensively adopted since the 1970s. This study is timely because the Wanda Horta theory forms the basis for nursing electronic documentation tools for all patients in an 800-bed university hospital in South Brazil and which has been implemented by the Brazilian Ministry of Education and Health in all university hospitals in Brazil. This move to a common national interface represents greater visibility for nursing and reinforces the importance of the nursing languages used inside that institution. Consequently, it also represents greater visibility for Brazil, where university hospitals are public and free of charge to the entire population.


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The Omaha System is a robust instrument that facilitates evidence-based practices, documentation, and information exchange across settings. The use of this tool provides essential information and clinical data that can be generated and aggregated into trends (Anderson & Sensmeier, 2011), thereby improving practice and facilitating and enhancing communication in different organizational structures. Therefore, the trends toward embracing information technology, automating, converting data to information, and influencing the best practices worldwide are some of the changes that are embraced by the accurate use of the Omaha System. Moreover, its use is imperative to achieve better quality of care and, consequently, better patient outcomes. In addition, the high level of agreement from our results reinforce the Omaha System as a world ontology for the conceptual framework of health, both in public health, as it has already been thoroughly adopted, as well as in this study, where it was used for comparing acute care data. This study strengthened the need for additional comparable studies across different nursing languages and settings and showed that it is possible to use the Omaha System for sharing knowledge and measuring nursing practices. The next step will be to incorporate the contributions of NANDA, NIC, and NOC to these frameworks as well as to link them to internationally coding systems, such as LOINC and SNOMED CT. Although the majority of the concepts were mapped and met agreement, it is important to emphasize that for this study, the tool mapped to the Omaha System was designed for the general assessment of inpatient adults. Customizations were used by different departments, and if they had been incorporated into the study, the researchers may have achieved a higher agreement rate. The sociocultural differences in the health system structures between these two countries may influence the mapping as well and should be taken into consideration in future research. Further research is necessary to establish similarities and comparable data among interventions and patient outcomes, as well as the cultural validity and exchange of the electronic health data.

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