The Omaha System: Bridging Home Care and Technology
There is an increasing demand for clinical information in home care at the same time reimbursement is being reduced. Home care agencies now are required to collect the Outcome and Assessment Information Set (OASIS) and use it for outcome-based quality improvement (OBQI) for care of all adult, non-maternity patients (Federal Register, January 25, 1999). However, the OASIS Data Set is not a comprehensive assessment tool, nor does it contain interventions and additional outcomes necessary for conducting OBQI. OASIS includes primarily end-result outcomes and case-mix factors, not outcomes focused on improvement in client knowledge and behavior (Shaughnessy & Crisler, 1995). The Problem Classification Scheme in the Omaha System provides a comprehensive assessment relevant to the variety of patients receiving services in home care (Martin & Scheet, 1992a). Additionally, the Intervention Scheme provides standardized language to describe the types of interventions provided. The Problem Rating Scale for Outcomes helps practitioners evaluate progress over time related to the patient's knowledge, behavior, and status. Together, when the OASIS data set and the Omaha System are integrated into a computerized information system, data can be collected efficiently and abstracted to perform OBQI (Westra, Martin, & Swan, 1996).

CareFacts Clinical Information Systems incorporates both of these data sets into an efficient computerized charting system used in home care and public health. Strategies used for successful implementation of the Omaha System within CareFacts in one home care agency will be discussed, along with benefits, lessons learned, and future recommendations.

Computerizing the Omaha System
CareFacts was designed as a charting and data collection tool for statistical quality control in community-based settings. By incorporating standardized terminology into routine charting, data can be collected in a cost-effective manner for quality improvement (Westra & Raup, 1995). The Omaha System (with the standardized data for problems, interventions, and outcomes) forms the backbone for the nursing process - assessing, diagnosing problems, developing care plans, documenting care, and reevaluating progress.

When the proposed Conditions of Participation requiring the collection of the OASIS data set were proposed, CareFacts incorporated this data in such a way that it compliments the Omaha System. Since the data are stored in a relational database, CareFacts' built-in report writer allows the user to query the data and abstract it for OBQI. Thus, variance in the OASIS outcomes can be examined by identifying the related nursing problems, interventions, and additional outcomes using the Omaha System.

An Agency's Experience of Implementing the Omaha System in CareFacts
Fairview Lakes Home Caring and Hospice (FLHC&H) is a Medicare certified, Joint Commission on Accreditation of Healthcare Organizations (JCAH) accredited comprehensive home care and hospice agency which implemented the Omaha System using CareFacts. FLHC&H provides care in eight rural counties with traditional home care services, hospice, infusion therapy, and maternal-child health services (women with high risk pregnancies, postpartum follow-up, newborns, breast feeding, pediatrics, special needs children, etc.). Services also are provided by a variety of disciplines, including nursing, therapies (physical therapy, occupational therapy, speech therapy), social work, home health aide, homemaker, chaplain, and volunteers. Delivery of services is organized by teams based on specialty and/or geographic area served. Approximately 900 to 1000 clients per year receive services with about 29,000 home care visits per year and 3000 to 4000 patient days for hospice.

FLHC&H was interested in computerizing their charting system. Initially, they decided to implement a pilot project to determine the benefit of using the Omaha System and to compare computerized versus manual charting. At the time they selected CareFacts, they had limited knowledge of the Omaha System. To familiarize themselves with the Omaha System, two nurses attended an all day workshop. These two nurses trained the rest of the staff in a half-day inservice using a video tape and handouts developed by CareFacts about the Omaha System. The Pocket Guides (Martin & Scheet, 1992b) were purchased to assist nurses in developing care plans. Manual forms were developed to match the CareFacts' program for staff not using a computer. Following the introduction of the Omaha System, CareFacts training was provided to the group using CareFacts. As a part of this training, staff were taught how to conduct an assessment using the Omaha System, develop care plans, and document care. Users were taught how to document against the care plan during a visit, then rate the patient's knowledge, behavior, and status for each problem when care was provided. They also were taught how to update problems and interventions from the visit window so that nursing care plans accurately reflected the changing needs of patients. A handout, "Decision Rules for Care Planning," was used to assist agencies regarding how the Omaha System relates to compliance with regulatory requirements and the ability to document care appropriate with reimbursement needs. This handout also helps agencies relate Omaha System problems, interventions, and the outcome ratings associated with the medical diagnoses, treatment codes, and goals on the HCFA 485 form.

Benefits of Using a Computerized Program with the Omaha System
The goals of computerizing the charting system at FLHC&H were determined prior to implementation. These were to improve the efficiency and effectiveness of care provided. The agency also was interested in maintaining or improving staff satisfaction when changing their documentation system.

Base-line data were collected prior to implementing the Omaha System and compared over time. This included examining the overall goals for the agency, as well as comparing the use of the computerized versus manual implementation of the Omaha System. Satisfaction was measured with a survey developed by the agency. Overall, charting improved in readibility and appearance for all users. Since there was consistency in the language used for documentation, communication was improved among staff. Initially, both computer users and manual system users decreased in productivity due to learning a new charting system. The computer users expressed a higher level of frustration since they were learning both the Omaha System and the computer program at the same time. However, after they became familiar with CareFacts, they had higher productivity than staff using the manual forms.

Once the changes had been fully implemented, comparisons were made in average hours per visit for case managers and staff. Case managers average hours per visit (total hours worked divided by total visits) went from 15.86 hours to 12.42 hour (these hours reflect the number of other responsibilities case managers have in addition to patient care). Staff nurses went from 5.41 hours to 3.0 hours. This reflects a 21.7% decrease for case managers, and a 44.5% decrease for staff nurses. Staff satisfaction was evaluated before and after implementation. Computer users increased in satisfaction while those on the manual system maintained their initial level of satisfaction with charting.

Lessons Learned and Future Recommendations
The amount of time to implement a system can not be underestimated. Initially, it was anticipated that the staff would improve in productivity within six months. In fact, it took approximately 9 to 12 months to demonstrate improvement in productivity.

In the future, several additional steps might improve productivity more rapidly. One is to put more emphasis on education related to the Omaha System. For instance, having staff develop standardized care plans for common diagnoses, may have helped them learn the Omaha System more quickly. CareFacts was designed to produce standardized data while having flexibility in the way the program can be used. The development of work flow processes or diagrams may have helped staff to learn the program more quickly based on their own style of work.

Additional features added later to CareFacts would have improved productivity earlier. For instance, a feature, "Assess as Adequate," was added to allow users to select all adequate problems at a single time rather than requiring the user to go in and out of multiple windows to evaluate each problem. Staff struggled with trying to identify where to put information and what the impact of their charting would be. If data had been analyzed, aggregating information across clients, staff may have been able to make decisions about the best way to chart more easily. For instance, staff were uncertain about how often it was necessary or appropriate to do outcome ratings for clients. They also were uncertain about the best way to construct care plans; they asked such questions as the number of problems to put on the care plan, the number of interventions, and whether these were important issues.

One of the major purposes of CareFacts is to conduct statistical quality control. This was not done during the implementation process. In the future, it is recommended that management reports be run in CareFacts beginning within the first month of implementation. Information such as the number of nursing diagnoses, types of diagnoses, and changes in outcome ratings per diagnosis would be useful. With the integration of OASIS in CareFacts, demonstrating outcomes for groups of patients and then looking at the differences in patient knowledge and behavior or interventions performed would be useful for understanding variances in outcomes.

Training associated with the Omaha System and implementing CareFacts improved overall productivity at FLHC&H. The agency has purchased additional licenses to continue moving toward all staff using CareFacts. Additional evaluation of the effect on productivity needs to be continued. Additionally, the agency purchased the scheduling and billing module to reduce redundant data entry across functions. Evaluation will be needed to look at the impact on time saved for support staff as well as clinicians and case managers. As the OASIS deadlines draw near, the agency will be able to meet the new regulatory demands using CareFacts with the integration of this data along with the Omaha System for comprehensive charting and outcome-based quality improvement.