DEPENDABLE SYSTEMS FOR QUALITY HEALTHCARE

INTRODUCTION
The healthcare is undergoing a dramatic transformation from today’s inefficient, costly,
manually intensive, crisis driven model of care delivery to a more efficient, consumer-centric,
science-based model that proactively focuses on health management.
The electronic health record (EHR) will form the foundation for pervasive, personalized,
and science-based care. Other key applications are clinical information systems (CIS) with
integrated, outcomes-based decision support, clinical knowledge bases, computerized physician
order entry (CPOE), electronic prescribing, consumer knowledge bases and decision support, and
supply chain automation.
The international Council of nurses (ICN) Code of ethics for Nurses affirms that the
nurse “holds in confidence personal information” and “ensures that the use of technology… [Is]
compatible with the safety, dignity, and rights of the people” (ICN, 2000).

DEPENDABILITY COMPRISES THE FOLLOWING SIX ATTRIBUTES:

1. System reliability: The system consistently behaves in the same way.
2. Service availability: Required services are present and usable when they are needed.
3. Confidentiality: Sensitive information is disclosed only to those authorized to see it.
4. Data integrity: Data are not corrupted or destroyed.
5. Responsiveness: The system responds to user input within an expected and acceptable time
period.
6. Safety: The system does not cause harm.
GUIDELINES FOR DEPENDABLE SYSTEMS
All computer systems are vulnerable to both human-created threats, such as malicious code
attacks and software bugs, and natural threats, such as hardware aging and earthquakes.
GUIDELINE 1: ARCHITECT FOR DEPENDABILITY
A fundamental principle of system architecture is that enterprise system architecture should be
developed from the bottom up so that no critical component is dependent on a component less
trustworthy than itself.
GUIDELINE 2: ANTICIPATE FAILURES
Unfortunately, minimizing complexity is more easily said than done. Consistent with Moore’s
law` (Moore, 1965), the speed of processors in doubling every 18 months, while the cost for that
computing power is halving within the same time period.
GUIDELINE 3: ANTICIPATE SUCCESS
The systems planning process should anticipate business success-and the consequential need for
larger networks, more systems, new applications, and additional integration.
GUIDELINE 4: HIRE METICULOUS MANAGERS
Good system administrators meticulously monitor and manage system and network performance,
using out-of-band tools that do not themselves affect performance.
GUIDLINE 5: DON’T BE ADVENTUROUS
For dependability, one should use only proven methods, tools, technologies, and products that
have been in production, under conditions, and at a scale similar to the intended environment.
 ASSESSING THE HEALTHCARE INDUSTRY
Healthcare clearly has a need for dependable systems--both now and after the transformation, as
the industry becomes increasingly dependent on IT in the delivery of patient care.
 HEALTHCARE ARCHITECTURE
For adherence to the first guideline “architect for dependability” the clinical care provider
community gets a barely passing grade of “D.” Healthcare organizations build—or perhaps
“compose’—their systems from the top down rather than from the bottom up.
The five specified physical safeguards also contribute to system dependability by
requiring that facilities, workstations, devices, and media be protected.
1. Access control, including unique user identification and an emergency access
procedure
2. Audit controls
3. Data integrity protection
 4. Person or entity authentication
5. Transmission security

 ANTICIPATING FAILURES
For adherence to the second guideline “expect failures” the clinical care provider community
gets another grade of “D.” Medical technology and prescription drugs, as well as clinical
treatment protocols, are required to undergo extensive validation before they can be used in
clinical practice.
Other healthcare organizations can be grateful for Care Group’s CIO’s willingness to
share the details of his experience so that they might benefit from the lessons learned
(Berinato, 2003)
 IT MANAGEMENT
For the fourth guideline “hire meticulous managers” the clinical care provider community has
been assigned a mediocre grade of “C”. Many provider organizations truly do recognize the
criticality of IT to their business success.
These organizations have hired IT managers who appreciate the important role of IT in
healthcare in healthcare environment and who recognize the need for dependable systems
that can anticipate and recover the failures.
 ADVENTUROUS TECHNOLOGIES IN HEALTHCARE
The fifth and final guideline “don’t be adventurous” is the most difficult to assess for healthcare.
On the one hand, healthcare givers typically are not early adopters. But on other hand, they seem
to cast fate to the wind or technologies that catch their collective fancy.
Healthcare clinicians, including nurses, historically and typically are very resistant to
change, largely because they are taught to be circumspect in considering new approaches,
treatment protocols, and drug regimens.
 NURSING MINIMUM DATA SET SYSTEMS

INTRODUCTION
Clinical nursing visibility from national to international contexts. The identification of the
NMDS visionary work begun in the united states in 1980s by Werly and Lang ( 1988), has
indeed spurred activity extending to national efforts to develop similar data sets around the
world. Moreover, these national efforts have supported an initiative to develop an international i-
NMDS.
NMDS historical summary:
The NMDS identifies essential, common, and core data elements to be collected for all patients/
clients receiving nursing care.
NMDS- is a standardized approach that facilitates the abstraction of these minimum, common,
essential core data elements to describe nursing practice from both paper and electronic records
- it is intended for use in all settings where nurses provide care, spanning. 1977- The
NMDS was conceptualized through a small group work at the nursing information systems
(NISs) conference held at the University of Illinois College of nursing.
1985- Werly and colleagues took the NMDS forward at the NMDS conference held at the
University of Wisconsin- Milwaukee School of nursing.
It was during this invitational conference that the NMDS was developed consensually through
the efforts of 64 conference participants and formalized by Werly and Lang, 1988.

THREE BROAD CATEGORIES OF ELEMENTS OF NMDS:

™ A) Nursing care
™ B) Patients or client demographics
™ C) Service elements

NURSING CARE ELEMENTS:

v Nursing diagnosis
v Nursing intervention
v Nursing outcome
v Intensity of nursing care
PATIENT OR CLIENT DEMOGRAPHIC ELEMENTS:
v Personal identification
v Date of birth
v Sex
v Race and ethnicity
v Residence

SERVICE ELEMENTS:
v Unique facility or service agency number
v Unique health record number or patient or client
v Unique number of principle registered nurse provider
v Episode admission or encounter date
v Discharge or termination date
v Disposition of patient or client
v Expected payer for most of this bill (anticipated financial guarantor for services).

™ Aim of the NMDS – is not to be redundant of other data sets, but rather to identify what are
the minimal data needed to be collected from records of patients receiving nursing care.
™ The NMDS - was developed by building on the foundation established by the U.S. uniform
hospital discharge data set (UHDDS).

EIGHT BENEFITS OF THE NMDS:

™ Access to comparable, minimum nursing care, and resources data on local, regional, national,
and international levels.
™ Enhanced documentation of nursing care provided.
™ Identification of trends related to patient or client problems and nursing care provided.
™ Impetus to improved costing of nursing services.
™ Improve data for quality assurance evaluation.
™ Impetus to further development and refinement of NISs.
™ Comparative research on nursing diagnoses, nursing interventions, nursing outcomes,
intensity of nursing care, and referral for further nursing services
™ Contribution toward advancing nursing as a research-based discipline.

Standards and research Era- twenty- first century:

™ The NMDS influenced the work of the professional nurses association (ANA) recognized the
NMDS as the minimum data elements to be included in any data set or patient record.
™ The ANA consequently established the American nurse’s association steering committee on
data bases to support clinical nursing practice
™ This committee launched a recognition process for standardized nursing vocabularies needed
to capture the NMDS data elements for nursing diagnoses, interventions, and outcomes in a
patient record.

11 languages have been recognized by ANA 2004 and two data sets:
Languages:
Ø ABC codes
Ø Clinical care classification (ccc) (formerly home
Ø Health care classification)
Ø International classification for nursing practice (ICNP)
Ø Logical observation identifiers names and codes (LOINC)
Ø NANDA- nursing diagnoses, definitions, and classification
Ø Nursing outcomes classification (NOC)
Ø Nursing interventions classification (NIC) system
Ø Omaha System
Ø Patient care data set ( PCDS)
Ø Perioperative nursing data set (PNDS)
 DATA SETS:
v Nursing minimum data set (NMDS)
v Nursing management minimum data set (NMMDS)
v The NMDS – serves as a key component of the standards developed by the nursing
information & data set evaluation center(NIDSEC).
v NIDSEC develops and disseminates standards related to nomenclature, clinical associations,
clinical data repositories, and system characteristics/ decision support/ contextual variables
pertaining to data sets in information systems that support the documentation of nursing practice.

NATIONAL NURSING MINIMUM DATA SETS:

Established NMDS:
The early NMDS work in the United States spurred the development of NMDS in numerous
other countries. To date seven countries have identified NMDS system:
1. Australia
2. Canada
3. Belgium
4. Iceland
5. Netherlands
6. Switzerland
7. Thailand

NMDS AND DATA ELEMENTS:

™ Environment:
ü Unit/cost center identifier
ü Type
ü Patient/client population
ü Volume
ü Accreditation
ü Organizational decision making power
ü Environmental complexity
ü Patient/client accessibility
ü Method of care delivery
ü Clinical decision making complexity
ü Nursing care:
ü Management demographic profile
ü Staffing
ü Staff demographic profile staff satisfaction
ü Financial resources:
ü Payer type reimbursement
ü Budget
ü Expense

NMDS relationship to international nursing minimum data set (i-NMDS)

Evolution of concepts:
The i-NMDS includes core internationally relevant, essential, minimum data elements to be
collected in the course for providing nursing care.
These data can provide information to describe, compare, and examine nursing practice around
the globe.
i-NMDS- is intended to build on the efforts already underway in individual countries. It is
imperative that the national health care infrastructure supports the collection and reuse of nursing
data.
Purposes:
The contribution of nursing care and nurses is essential to health care globally. The i-NMDS as a
key data set will support:
 Describing the human phenomena, nursing interventions, care outcomes, and resource
consumption related to nursing services.
 Improving the performance of healthcare systems and the nurses working within these
systems worldwide.
 Enhancing the capacity of nursing and midwifery services
 Testing evidence-based practice improvements
 Addressing the nursing shortage, inadequate working conditions, poor distribution and
inappropriate utilization of nursing personnel, and the challenges as well as opportunities
of global technological innovations.
 Empowering the public internationally.