The Omaha System: Past, Present and Future
Karen S. Martin, RN, MSN, FAAN
The Omaha System is a research-based, comprehensive taxonomy that consists of the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes. This article summarizes the history, structure, content, and use of the System. For more details about the Omaha System, refer to the other articles in this issue as well as numerous books, chapters, and articles (Bednarz, 1998; Frenn, Lundeen, Martin, Reisch, & Wilson, 1996; Lowry, Martin, & Newman, in press; Marek, 1997; Martin, 1997a; Martin, 1997b; Martin & Bowles, in press; Martin, Larson, Gorski, & Hayko, 1997; Martin & Martin, 1997; Martin & Norris, 1996; Martin, Norris, & Leak, 1999; Martin & Scheet, 1992a; Martin & Scheet, 1992b; Martin, Scheet, & Stegman, 1993; Reif & Martin, 1996; Scoates, Fishman, & McAdam, 1996; Wills & Sloan, 1996).
Work on the Omaha System began in 1970. During the early years, information was disseminated through workshops and speeches. The first article was published in 1981. Initial adopters of the Omaha System were community-focused home care, public health, and school practice settings in this country. Both the number and type of Omaha System adopters are expanding dramatically to include nursing center staff, hospital-based and managed care case managers, nursing educators, acute care setting staff, researchers, members of various disciplines, software vendors, and the international community. These trends are due in part to the increasing elder population, the shift of health care delivery from institutions to the community setting, and the advances in technology. The rich diversity of Omaha System implementation is illustrated by the other authors in this issue; they included their Omaha System publications in their reference lists.
Between 1975 and 1986, three research projects were conducted at the Visiting Nurse Association (VNA) of Omaha and were funded by the Division of Nursing, US DHHS. The purpose of the research was to develop and refine the Omaha System. Further research designed to address reliability, validity, and useability was conducted between 1989 and 1993; the research was funded by a National Institute of Nursing Research, NIH RO-1 grant. An empirical approach was used throughout the research projects. Practicing clinicians employed by the VNA of Omaha and seven diverse test sites located throughout the United States collected actual client and family data and submitted those data for inclusion in the Omaha System. Numerous other individuals and groups participated in the research as advisory committee members and consultants. From the beginning of the Omaha System's development, the terms, codes, and definitions have existed in the public domain so that they are equally accessible to practitioners, administrators, students, faculty, and other potential users.
The Omaha System is based on the dynamic, interactive nature of the nursing or problem solving process, the clinician-client relationship, and concepts of diagnostic reasoning, clinical judgment, and quality improvement. Because the Omaha System follows taxonomic or classification principles, it consists of terms and codes arranged from general to specific. From the onset, the entire Omaha System was intended to be as comprehensive and yet as brief as possible, and to be useful to nurses as well as members of various disciplines in multiple settings. Terms selected for inclusion were simple, clear, concise, and easily understood by health care providers and the general public. Those terms were considered to be appropriate for clients and families of all ages, medical diagnoses, socio-economic ranges, spiritual beliefs, and cultures. The goal of Omaha System project staff, test sites, and funding sources was to develop a taxonomy that would provide a useful guide for practice, a method for documentation, and a framework for information management.
Problem Classification Scheme
The Problem Classification Scheme is a comprehensive client-focused taxonomy that describes clients' health related concerns and problems. The terms, codes, and definitions of the Scheme provide a method for the user to assess the individual client or family, and to collect, sort, classify, document, and analyze client data. It helps the user separate essential from nonessential data and identify patterns in those data.
The Problem Classification Scheme consists of four levels: domains, problems, modifiers, and signs/symptoms. The four domains are general areas that provide an organizational structure for the Scheme and offer a holistic approach to health care practice. The domains are Environmental, Psychosocial, Physiological, and Health Related Behaviors. Client problems, the second level of the Scheme, are the 40 nursing diagnoses that represent matters of difficulty and concern that historically, presently, or potentially adversely affect any aspect of the client's well being. Income, Grief, Circulation, and Nutrition are examples of client problems. Two sets of modifiers appear at the third level of the Scheme and are used in conjunction with problems. The user identifies a problem as either an individual or family problem and as either a health promotion, potential, or actual problem. Using two modifiers with a problem increases applicability across the health-illness continuum and adds specificity to the problem. Some users have expanded the individual and family modifiers to include groups and communities. The fourth level of the Problem Classification Scheme involves a cluster of signs and symptoms specific to each problem. For example, signs and symptoms for the problem, Income, include uninsured medical expenses and difficulty buying necessities.
The Intervention Scheme is a comprehensive taxonomy that describes health care related actions or activities. The terms, codes, and definitions of the Scheme are designed to help users identify and document both plans and interventions for clients' specific problems or nursing diagnoses. The Scheme represents a research-based effort that links interventions with diagnoses.
The first level of the Intervention Scheme is comprised of four broad categories: Health Teaching, Guidance, and Counseling; Treatments and Procedures; Case Management; and Surveillance. One or more categories are used to develop, describe, and document a plan or intervention specific to a client problem. The second level of the Scheme is an alphabetical listing of 62 targets. Targets are defined as objects of health related interventions or activities, and further describe problem-specific intervention categories. For the problem, Grief, and the intervention category, Health Teaching, Guidance, and Counseling, a possible target is communication, and for the category, Surveillance, a possible target is coping skills. For Circulation and the intervention category, Health Teaching, Guidance, and Counseling, possible targets are cardiac care and signs/symptoms-physical. The target, signs/symptoms-physical, is frequently used with the intervention category, Treatments and Procedures, and the category, Surveillance. The third level of the Intervention Scheme is designed for client-specific information. Pertinent, concise words or phrases are generated by users as they develop plans or document care provided to a specific client. Although not part of the research projects, VNA of Omaha staff organized their suggestions into care planning guides (Martin & Scheet, 1992b).
Problem Rating Scale for Outcomes
The Problem Rating Scale for Outcomes is a comprehensive framework designed to measure clients' health related changes. The terms, codes, and definitions of the Scale were designed to measure problem-specific knowledge, behavior, and status throughout the time of client service. When establishing the initial ratings for client problems, the user creates an independent data baseline to capture the condition and circumstances of the client at a given point in time. This admission baseline is used to compare and contrast the client's condition and circumstances with the ratings completed at later intervals and at client dismissal. The comparison or change in ratings over time can be used to identify client progress in relation to the effectiveness of interventions and the plan of care.
The Problem Rating Scale for Outcomes is a 5-point, ordinal scale comprised of Knowledge, Behavior, and Status subscales. Knowledge is the ability of the client to remember and interpret information. Behavior is the observable responses, actions, or activities of the client fitting the occasion or purpose. Status is the condition of the client in relation to objective and subjective defining characteristics. The scale for each of the concepts has five categories or degrees for response. For example, for problems such as Grief and Circulation, the user would identify and document baseline Knowledge, Behavior, and Status ratings during the first home visit, hospital shift, or clinic encounter. Ratings would again be identified at appropriate intervals and when the client is dismissed from service.
Many of the health education, technical, case management, and communication skills needed in community-focused practice settings are similar to those needed in acute care and residential long-term care facilities. The challenges are escalating for clinicians and administrators as health delivery shifts from the acute care to the community setting, mergers and the philosophy of seamless health care increase, and reimbursement and length of stay decrease. It is essential that nurses and other health care providers develop skills to function and/or to communicate across multiple settings. Clinicians need to be competent with client assessment and diagnosis, intervention, and outcome measurement. They need to be competent collecting clinical data, documenting care, using automated record systems, transforming clinical data to information, and communicating that information to others.
When implemented in a nursing practice or educational setting, the Omaha System is a model that can assist clinicians and administrators with practice, documentation, and information management. The System can be used to introduce new staff or students to professional practice through a standardized, easily understood system of client problems, nursing interventions, and client outcomes. For experienced staff, the Omaha System offers a series of cues or feedback loops that help remind the users about possible client problems and interventions and about ways to evaluate the effect of the care provided. Data generated by using the Omaha System in manual or automated client records can provide clinicians, administrators, and researchers with essential information. These clinical data can be converted into trends which can be used to improve practice, facilitate communication, complete reports including those for third party payers, meet accreditation requirements, plan new agency programs, and interface with other, non-clinical information within the agency's management information system. The increased percent of clients whose health care services are reimbursed by managed care illustrates the challenges faced by clinicians and administrators. Managed care companies want their enrollees to improve their health, prevent illness, and limit the amount of expensive sickness care they require. Therefore, managed care is changing the type of programs agencies offer, their need for valid and reliable clinical data, and the types of clients they serve (Martin & Martin, 1997).
Adopters of the Omaha System represent practice, education, and research as noted in numerous references mentioned at the beginning of this article. The last systematic survey of users was published in the 1992 Omaha System text. At that time, more than 200 community focused practice settings were identified as adopters; these agencies employed almost 4000 nurse users. Although some agencies and groups developed automated systems for their own use, many used paper and pen client record systems. The number and type of service settings that use the Omaha System have increased dramatically since 1992. The availability of clinical information system software based on the Omaha System is a primary reason for the increase in adopters in practice settings. Westra describes an example of such software in this issue; note that this Omaha System software includes the OASIS data set, a new Health Care Financing Administration requirement for home health agencies who receive Medicare reimbursement.
The number and type of educators who are using the Omaha System have also increased dramatically. Trends that are responsible include adoption of curricula that are community-focused, introduction of more technology including automation, and valuing of standardized clinical data. The University of Oklahoma, Oklahoma City, OK (Merrill, Hieber, Moran, & Weatherby, 1998) and University of South Dakota, Vermillion, SD are examples of baccalaureate and associate degree programs where curricula are based on the Omaha System. The availability of Omaha System focused software such as the Nightingale Tracker described in this issue by Elfrink is another important reason for the increase in use.
Early Omaha System research was conducted by staff at the VNA of Omaha and was summarized earlier in this article. During the last fifteen years, a critical mass of others including staff in service settings, faculty, doctoral students, and masters students began conducting and reporting research (Allen, 1994; Cell, Peters, & Gordon, 1984; Coenen, Marek, & Lundeen, 1996; Doran, Sampson, Staus, Ahern, & Schiro, 1997; Hays, 1992; Helberg, 1988; Marek, 1996; McGourthy, 1999; Mundt, 1988; Pasquale, 1987; Sampson, 1998; Zielstorff, Tronni, Basque, Griffin, & Welebob, 1998). Elfrink refers to the Nightingale Tracker research in the issue. Bowles also describes her doctoral dissertation in this issue, the first major Omaha System research conducted in an acute care setting. The increase in research is another important trend because findings from such projects will be used to refine and revise the Omaha System.
Publications and workshops were previously mentioned as the first ways to learn about the Omaha System. Both continue to be popular methods to disseminate information. As the number and type of users increase, a critical mass of practice, education, and research focused articles are being published by many authors. One recent book includes teaching guides designed for clinicians or students to use with clients; the guides are organized according to the Problem Classification Scheme (Martin, Larson, Gorski, & Hayko, 1997). The two books published by Saunders (Martin & Scheet, 1992a & b) continue to be the most complete publications. The comprehensive book includes a history of the development and research, a detailed description of the System, planning and implementation suggestions, application chapters, and comments about automation, quality improvement, and the future. Each application chapter has a focus such as home health agencies, public health agencies, emerging settings, nursing education, and school health. Application chapters and the appendix also include paper and pen record forms and case studies. The pocket guide includes different material and is designed as a reference for the clinician or student who is using the Omaha System.
Two Omaha System videotapes are available. FITNE, Inc., Athens, OH produced one videotape about the history and content of the System, and another that includes home health and occupational health case studies. These tapes are useful for colleges of nursing who purchase the Nightingale Tracker, but are also helpful to other faculty and practice settings who are introducing the Omaha System to students and staff.
The Omaha System is available electronically. For a few years early in the 1980s, the VNA of Omaha developed and sold software. Soon other groups and agencies began to develop their own software. In the 1990s, software companies started developing commercially available software for home health agencies, public health departments, nursing centers, and colleges of nursing. Some of those companies have web sites on the Internet.
The Internet includes more information about the Omaha System. The University of Florida College of Nursing, Gainesville recently developed an Omaha System web site (http://con.ufl.edu/omaha/). The purpose is to share general information, references, and case studies developed by FITNE Center for Excellence faculty. The site also contains a link to subscribe to the Omaha System's electronic mailing list. FITNE, Inc. staff also added a home health care case study to their Nightingale Tracker web site (http://www.ev.net/fitne/tracker/casestudies/introduction.html).
The Omaha System is one of the six vocabularies recognized and disseminated by the American Nurses Association to represent important clinical data for the nursing profession and enhance communication (Helmlinger, 1998; Lang, 1995). It was selected by the participants of the Community Nurse Organization Project, a demonstration project funded by Health Care Financing Administration. The System is included in the National Library of Medicine's Unified Medical Language System Metathesaurus (Helmlinger, 1998; McCormick, et al, 1994; Zielstorff, Cimino, Barnett, Hassan, & Blewett, 1992). It is also included in the ANSI HISB Inventory of Clinical Information Standards, and in the accreditation standards of the Joint Commission on Accreditation for Health Care Organizations and CHAP (National League for Nursing). Discussions about inclusion in SNOMED International are occurring.
Translation of the Omaha System into Danish occurred about 1985. Since then, the terms, codes, and definitions have been translated into a number of languages. Work by the International Council of Nurses on the International Classification for Nursing Practice introduced the Omaha System to nurses in many countries and stimulated interest in adoption. Requests for international site visits and presentations have resulted. Clinicians and administrators, educators and students, and researchers are beginning to use the Omaha System in paper and pen and automated versions and to write for publication. The Omaha System pocket guide was translated into Japanese in 1997; other translations are pending.
The use of the Omaha System in practice, education, and research needs to continue and expand nationally and internationally. It is important for such information to be published, presented, indexed, and shared with the nursing and health care communities. Plans to conduct a survey, initiate a users group, and develop methods to update and publish revised editions of the Omaha System are being discussed. These steps are necessary for the continuation and growth of the System.