Article Content


The Omaha System International Conference took place in Eagan, MN, on April 16 to 18, 2009. Those attending were from Estonia, Hong Kong, New Zealand, The Netherlands, and 17 states. More than 40 representatives of practice, education, research, and information technology presented information about their use of the Omaha System. They are employed in home care, public health, hospice, acute care, case management, long-term care, nurse-managed centers, parish nursing, child care, and university settings. The Conference was presented by Martin Associates, and the school host was the University of Minnesota School of Nursing (UMN-SoN).

Figure 1 - Click to enlarge in new windowFIGURE 1. Karen Monsen, poster presenter.

Partnership was the conference theme. Presentations focused on a common goal: working in partnership to improve the quality of healthcare services. The need for data exchange and interoperability permeated discussions. Applications of standards, meaningful use of electronic records, and partnership results were highlighted.


Applications of Standards

A standardized terminology such as the Omaha System is essential for documentation and information management. International participants described current initiatives to standardize and automate healthcare documentation in their countries. The diverse initiatives were designed to describe the recipients of service; quantify practice and the outcomes of that practice; integrate clinical, statistical, and financial data; and communicate data efficiently and economically. The need for nurses and other healthcare professionals to work as partners with managers, administrators, system engineers, and software developers was emphasized.


Meaningful Use of Electronic Health Records

Electronic health records (EHRs) demand standardization to capture data meaningfully. Clear, consistent, and accurate use of a standardized terminology such as the Omaha System requires effort. Participants indicated that they selected the Omaha System because of the simplicity and comprehensiveness of its three relational components (Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes). Many speakers emphasized the need to have a vision, strategic plan, and adequate resources. They shared "lessons learned" during their planning, implementation, maintenance, and evaluation phases. As the rich discussions surrounding these lessons illustrated, new adopters can benefit from the insights gained by experienced users. Many resources are available online at the Omaha System Web site, at workshops and conferences, in the literature, from vendors, and through networking.

Figure 2 - Click to enlarge in new windowFIGURE 2. Standing L to R: Karen Martin, Karen Lindberg, Pam Correll, Judy Riemer, Karen Monsen, Madeleine Kerr, Planning Committee; seated: Louis Henry, Jr, speaker

Partnership Results

Omaha System partnerships are achieving the kinds of results that administrators and decision makers expect from EHR data.


* State and local public health agencies and university researchers are partnering to evaluate the effectiveness of a statewide family home visiting program using Omaha System intervention and outcomes data.


* Systems engineers and home care nurses in The Netherlands are transforming care delivery for their patients and measuring outcomes of care.


* Public health administrators, university educators, state and local public health staff, and systems engineers are developing partnerships to enhance data and practice quality for diverse community programs.


* Acute care and ambulatory care settings are partnering to improve discharge communication, follow-up, and client care.


* Public health nursing experts are working with Omaha System users to develop evidencebased pathways that can be disseminated via computerized documentation systems.


* Home care staff initiated a multidisciplinary quality improvement program designed to improve their clients' pain and dyspnea scores; in the process, they increased their partnerships with their clients and their clients' families.


* Nursing and computer science researchers are partnering to use sophisticated data mining techniques to discover new intervention models and test predictive validity.


* Nursing researchers, advanced practice nurses, a major insurance company, and a major health plan are working together to evaluate the success and cost-effectiveness of a transitional care program, translating evidence-based research into standards of care.


* Researchers, educators, and students from nursing, social work, and pharmacy formed partnerships with community-based health workers (promotoras) to jointly plan, implement, and evaluate care for underserved populations with chronic health problems.


* Two schools of nursing developed a partnership with the assistance of an alumni businessman. His sponsorship enabled two graduate students to attend the conference, and he is providing additional encouragement and financial opportunities for students and faculty to incorporate the Omaha System into their simulation laboratory.



It was evident from the presentations and discussions that the Omaha System enables the development and maintenance of exciting partnerships and exchange of clinical data. The Omaha System exists in the public domain, has been recognized as a standardized terminology by the American Nurses Association since 1992, passed the Healthcare Information Technology Standards Panel selection criteria in 2007, and is registered (recognized) by Health Level Seven. It is integrated into the National Library of Medicine's Metathesaurus; Logical Observation Identifiers, Names, and Codes; and SNOMED-CT.


Contributed by Karen S. Martin, RN, MSN, FAAN and Karen A. Monsen, RN, PhD.



Rutgers' College of Nursing Center for Professional Development hosted the 27th Annual Rutgers Nursing Technology Conference held from April 24 to 26 in Arlington, VA. "Bridging the Technology Gap Between Nursing Service and Education" was the official title, with the concept of collaboration emphasized in all the keynote talks. The proceedings given to all participants at registration contained abstracts and, often, PowerPoint slides for almost all the simultaneous sessions so that participants could gain an idea of what they had missed when confronted with the "How can I be in more than one place at the same time?" conflict. There were 130 participants.


The conference opened with the keynote talk of Diane Skiba, PhD, FAAN, FACMI, "Nursing Education Collaboration With Nursing Service." She emphasized the need for service and education to collaborate to reach the common goal of preparing high-quality nurses. Given the federal push for EHRs, it is necessary to prepare nurses to use them as a tool. It is not enough, in either education or service, to just teach EHR users what button to push; they need to know how to use the system so that it becomes a tool like the stethoscope and use it to find data and create information and knowledge. The best way to meet these demands, as well as others, is collaboration with service, a vendor, or both.


Dr Skiba pointed out that healthcare is on the federal agenda with the goal of remedying the situation in which only 9% of healthcare agencies have anything resembling a full electronic medical record. Most agencies, however, have started this journey. One of the reasons for introducing an EHR, the ability to get data out, is confounded by the fact that today's electronic healthcare systems are designed with the idea of getting data in but make it difficult to use the data to produce evidence. Not only does this need to change, but also nurses must be educated to use this data for evidence-based care.


With the above ability of consumers to find information previously restricted to healthcare personnel, the nature of healthcare is changing. Consumers are engaged in learning about any disease condition they or a loved one may have. Although novice searchers at the beginning of an illness, as their condition becomes worse, their search skills improve. As a result, consumers want different things from their provider.


Healthcare at present has ignored the ability of the Internet and Web-based applications to contribute to health information technology (HIT). While healthcare was in standards meetings, Google and Microsoft jumped into the marketplace with personal health records. Dr Eysenbach's article in the Journal of Internet Medical Research about combining personal health records with social networking in healthcare ( provides more examples of Web 2.0 uses in healthcare. One of the things necessary to accommodate this new word is to prepare nurses to show caring in non-face-to-face situations.


Data visualization, which means data representation beyond graphs, was another topic in Dr Skiba's presentation. Taking complex data and presenting it in ways that people can understand are tools that will be needed in healthcare, both in our electronic records and for working with consumers. (Search the Web for data visualization for some excellent examples of her meaning.)


Saturday morning opened with a joint presentation by Jim Cato, EdD, MSN, RN, CRNA, MHS, CPEHR; Kathryn Bowles, PhD, RN, FAAN; and Patricia Abbott, PhD, RN, FAAN, FACMI, about a joint partnership among the Eclipsys Corporation, the University of Pennsylvania, and Johns Hopkins Schools of Nursing to bring EHR to nursing students. Dr Cato, who is the vice president of nursing at Eclipsys, opened the presentation. He informed us that this collaboration was a result of the parties involved realizing that nurses today function in a complex environment that requires "new age" education. Nurses must have confidence in their skills in effectively using technology to participate in decision making in new healthcare environments. To meet these needs, the curriculum and teaching methods must address the emerging practice realities by linking practice needs with education.


"Creating a partnership is a slow process." It involves trust, hard work, high-level genuine support, and patience. Corporations and academia have different cultures and different missions. Corporations must satisfy the stockholders and lawyers, while education must satisfy various committees. The result is that faculty do not understand the culture of industry and the industry does not understand the academic culture; a situation that requires work by both sides. Benefits, however, can accrue to both parties. Vendors can realize product exposure and good public relations. They also learn about nursing workflow and other nursing issues that impact the next generation of their software. These partnerships also provide an established site for potential clients and offer the potential for joint research and the testing of new ideas.


Dr Bowles pointed out that schools of nursing benefit because students learn skills in cutting-edge nursing informatics, are prepared to participate in system selection, and become proactive informatics users instead of reactive. At the master's level, students are able to compare products and suggest modifications, understand linkages within the record, and develop deeper analysis and evaluation skills. Faculty and PhD students learn the interdependence of systems and appreciate the ability to use data.


The process involved in developing a partnership is lengthy. The contract alone took from February to October to develop. In creating a partnership like this, it is important that each party appoint a project manager who can sell the project. With the full support of all the chairs and the dean, the two schools of nursing organized faculty retreats to discuss the project. The ultimate goal was to integrate healthcare informatics at all levels of the program.


Dr Abbott reported that the goals were to increase the healthcare informatics competencies of their nursing graduates. It is hoped this will lead to the design of safe and efficient healthcare using HIT. This partnership will allow students to be taught to interact easily with technology and use the wealth of evidence in the health record to develop best practices in clinical care.


The reality of the collaboration revealed interesting outcomes. For one, the school had the advanced version of the software, and students in the clinical areas found a mismatch between interface and functionality. Additionally, an educational system needs more granularity of data than the clinical area does because different purposes are served. The generation divide between the digital immigrants who did not grow up with technology and digital natives who did created certainty and uncertainty in the faculty.


Students who practiced outside of agencies related to the nursing schools had to chart using paper because the firewalls would not let them access the system. Additionally, for faculty grading purposes, reports had to be generated and printed. Still, the gains outweighed the difficulties, the faculty were engaged, creative thinking occurred, and everyone became aware of what is "behind the curtain" in healthcare records. When students cannot use the hospital system, they never develop these skills. Under this collaboration, students can learn electronic documentation and use of information as a nursing purpose. Dr Abbott ended with the thought that there is no stopping the train of progress, "If you are not part of the future, you are history."


The topic of Mary Anne Rizzolo,EdD, RN, FAAN, was "Are We Preparing Nursing Students to Function in a Technology Rich Environment?" She opened by asking the audience this question; only one participant thought we were. As early as 1974, the idea of health professionals needing education in informatics was introduced. It was the 1987 National League for Nursing (NLN) Guidelines for Basic Computer Education in Nursing by Judith Ronald and Diane Skiba that first officially addressed the competencies needed by nurses in informatics. Since then, there have been other calls for the use of healthcare informatics in the curriculum and practice areas, including the Institute of Medicine (IOM) reports. Progress, however, still feels like the child's game of "Chutes and Ladders," in which we take a few steps forward only to slide back down. However, one state's Board of Nursing, North Carolina, has mandated that schools of nursing incorporate the IOM core competencies, one of which is informatics.


In March 2006, the NLN's Informatics Competencies Task Group of the Educational Technology and Information Management Council sent separate but similar e-mail surveys to determine the level of informatics education in the curriculum to NLN member and nonmember faculty and nursing education administrators at schools of nursing, from the practical nurse to the doctoral level. The most disturbing findings from these surveys were that few faculty or administrators could differentiate between educational technology such as the use of PowerPoint, or the Web, and the practice of informatics. Comments such as "all courses are Web enhanced" and "informatics is available through the library and integrated into English class" demonstrated this confusion. One wrote that "Students are encouraged to e-mail instructors with questions, but that less than five percent take advantage of this." Preparing for the National Council Licensure Examination on the computer was also seen as informatics. Some, truthfully, admitted that they were not sure what informatics is. Thus, there is considerable confusion about what constitutes nursing informatics, which leads to the question of the quality of informatics education that students are receiving. The survey information was used to develop the NLN position statement about preparing the next generation of nurses ( The report includes recommendations for faculty, deans and chairs, and the NLN itself.


The results also spearheaded a program by the University of Colorado Health Sciences Center School of Nursing in Denver, Indiana University School of Nursing in Indianapolis, the University of Kansas in Kansas City, and the NLN, funded by a grant from the US Department of Health and Human Services, Health Resources and Services Administration's Division of Nursing to prepare nurse educators in informatics. Called the HITS (Health Information Technology) Scholar Program, it is to last for 5 years (see for more information on this program).


To promote the inclusion of informatics in the curriculum, educators and practitioners can seek partnerships and provide informatics resources. Practitioners can support faculty efforts and demonstrate informatics benefits to patients. Faculty can be a champion for their school and provide informatics resources for all. Both faculty and practitioners can expose faculty to informatics applications they can understand.


Saturday evening, there was a networking dinner at the Spy Museum, where we all had a chance to take on a different persona and undertake a spy mission, not virtually, but in a progression of dioramas. We had to memorize our character's persona and our mission then answer questions based on this information while being scrutinized by a virtual guard. There were other fascinating exhibits, including one on women spies, the most famous of whom was Mata Hari, whose exploits, alas, were mostly in her head. The dinner that followed honored Dr Mary Anne Rizzolo, who is retiring from the NLN in December. A slide show of events in her professional career was presented by Karen DuBois and Diane Skiba, along with remembrances by many attendees of the effect of Dr Rizzolo's many accomplishments.


The Sunday morning keynote speaker was Kathy Scott, PhD, RN, whose talk was "The Use of Technology to Promote Effective New Graduate Performance." She stated that to provide this, we need to challenge assumptions and use all the possible tools to create the best care possible. One of Banner Health System's four missions is to provide innovative approaches to new graduate education. This is accomplished through virtual training, simulations, and academies. Dr Scott stated that new nurses, or nurses changing specialities, need help with technical skills that otherwise can paralyze them. Banner Health has created a competency-based orientation program across all their seven state agencies. Their first efforts at providing this education were students viewing an instructor giving a lecture, something they found wasted time, dollars, and resources. Instead, they developed several centers, one of which is mobile for their rural facilities. These centers have high-fidelity manikins and equipment, also the Nintendo Wii. They have found that in 5 to 7 seconds using the Wii, which allows natural hand movements and the use of fine motor skills, they can determine if a person is qualified to perform a skill. The Wii has also been used with practitioners who have had bad outcomes to perfect their skills. To fund these centers, Dr Scott demonstrated that within 18 months, they would result in enough reduction in patients' hospital stays to fund the program. Available 24/7, they use competency-based, not time-based, training. The result has been more retention and more nurse satisfaction.


The primary focus of the training centers is to train new nurses and those new to a speciality. The secondary purpose is multidiscipline team training. They found that this gave all participants a view of others' world. Physicians learned about the problems and frustrations that nurses face, and nurses learned about the difficulties faced by physicians, all of which has led to a better understanding of the role of each.


New hires spend their first week in their home facility, then spend 2 weeks in basic skills simulations for their speciality area. The next 9 weeks are spent with their floor preceptor, where they integrate their skills into practice and move to independent care. After 12 weeks, they graduate, but they remain in residency for 1 year. Residency groups meet for 4 hours every month to examine professional issues such as delegation and scope of practice.


The conference concluded with the keynote speech "Where Do We Go From Here? How Do I Implement Collaboration Between Education, Services, and Other Partners" by Helen Connors, PhD, RN, DrPs (Hon), FAAN. Dr Connors started by examining the concept of collaboration. She defined it as "the process of two or more people coengaged in a process where the result is the emergence of shared understanding or a creative output." True collaboration is a process that needs attention; it does not develop by itself. There are various levels of collaboration. The lowest level is cooperation, which is seen in networking and cooperative work. The second level is coordination and involves partnerships. The highest level creates a merged and unified whole. Collaboration is needed if we are to reach the IOM goals of providing patient-centered care, work as interdisciplinary teams, use evidence-based practice, apply quality improvement, and effectively use informatics. Partnerships allow for expertise and resources to create better outcomes.


Collaboration, however, is a journey, not a destination. It is personal as well as procedural. When being developed, expect strain; "You are stepping out of your comfort zone, taking risks." Interpersonal relationships are an integral part of the process and must be cultivated. The first stage is to assemble and decide why the collaboration is needed. The next stage has been termed storm and order in the Bailey Koney model. In this stage, who plays what role is discussed as well as how to make it happen. "Norm and perform" follows, in which roles are decided and things are made to happen. The last stage, "transform and adjourn," is arrived at when the collaboration is complete and functioning.


The last stage has been arrived at by the Kansas University School of Nursing and the Cerner Corporation. This journey started with a handshake at a chance meeting of Dr Connors and Neil Patterson, chief executive officer of Cerner. Like the collaboration among Johns Hopkins, the University of Pennsylvania, and Eclipsys, the collaboration involved merging two different cultures whose metrics for measuring are different. It involved learning each other's differences and working through them, as well as working with lawyers on both sides.


The final collaboration created a health documentation system that is taught as part of skills. For example, when assessment is taught, students are taught to document on the system instead of on paper records. Students are also taught to use the information. Realizing that not every school is positioned to create this type of partnership, they created a center that can host other school's use of the system. Currently, there are many schools that take advantage of this program. As can be seen in the above discussion, the conference was very stimulating. Each of the keynote speakers added value to the general theme of collaboration, as did the individual sessions.


Contributed by Linda Q. Thede, PhD, RN-BC.



How do you engage a local nursing community in a discussion about HIT? This became a topic of discussion after the national TIGER Summit held in the fall of 2006 entitled "Evidence and Informatics Transforming Nursing." More than 100 leaders from across the nation created a vision to bridge the quality chasm with information technology, enabling nurses to use informatics in practice and education to provide safer, higher quality patient care. Since that time, hundreds of volunteers have joined the collaborative teams on nine key topics to accelerate the action plan. An executive summary of TIGER activities through 2008 was recently published and is available on the TIGER Web site (


The president of the Minnesota Nursing Informatics Group (MINING) at the time, Tess Settergren, returned from the summit ready to activate Minnesota nurses. She invited a TIGER Advisory Council member, Dean Connie Delaney from the UMN-SoN, to a MINING meeting to discuss the summit vision and action plan. At this meeting, it was decided that MINING and the UMN-SoN would develop and organize a Minnesota TIGER Summit to share national and local experiences with HIT and discuss issues related to the effective adoption of EHRs.


It was recognized that this was of importance to the broader nursing community. The Minnesota Organization of Leaders in Nursing and the Minnesota Association of Colleges of Nursing (MACN) were invited to cosponsor the meeting. The first Minnesota TIGER Summit was held in January 2008 in Minneapolis. It was designed to introduce the TIGER pillars and then provide local exemplars of the pillars in action. The participants came from all roles within nursing and also from outside the nursing profession. The response from 210 participants was overwhelmingly positive, with an especially positive response to the local exemplars.


Feedback from the first summit led the organizers plus the Minnesota Nursing Association (MNA) to plan a second summit in 2009. The second Minnesota TIGER Summit, "Springing Into Action," was convened in January 2009, with 174 participants attending the Summit. Almost all the attendees (96%) indicated overall that the conference and its practical application to their informatics work or practice were good, very good, or excellent. In addition, interest areas for further exploration included the following:


* The integration and incorporation of EHRs into diverse practice arenas


* Prevailing approaches to the adoption of new technologies focusing on legalities, overcoming challenges, and creating solutions, especially relating the use of voice recognition and data extractors


* Maintaining personalized care when using standardized electronic flow sheets


* Expanded discussion of successful EHR best practice experiences and lessons learned from hospital nurses at the bedside


* Strategies to increase collaboration from healthcare organizations for standardization of EHR across the country and the world


* EHR barrier identification, problem solving, and negotiations within healthcare organizations


* Active participation-hands-on learning through demonstrations/simulation



Tabletop breakout sessions offered opportunities for participants to discuss and share significant issues, ideas, and recommendations for improving practice in the face of new and evolving technologies and diminishing resources.


The energy and outcomes expressed by the Minnesota TIGER Summit participants were truly contagious. Participants were excitedly anticipating their ability to share the information with colleagues and administration. A few lessons learned for the next Summit and our constituents were the following:


* Increase time for interactive questions with speakers.


* Provide hands-on demonstrations and opportunities for practice.


* Create scorecards and other reports by data extraction.


* Address legal ramifications, challenges, and responsibilities associated with electronic documentation.


* Define and develop consistent processes for successful best practice implementations.


* Foster nursing informatics from a "bottom-up" involvement instead of top-down.



The Minnesota TIGER Summits have brought education, informatics, leadership, and clinical practice together around the informatics challenges we all face in our respective roles. There were a number of factors that contributed to the success of the Summit which united nursing professionals, who tend to have limited interaction professionally. The first factor that influenced the success of the Minnesota TIGER Summit was the national TIGER initiative, which provided Minnesota with a framework and vision to organize on a state level. The second success factor was the existence of four strong organizations, UMN-SoN, MINING, MACN, and MNA, who each brought their own constituency, along with a willingness to collaborate for the benefit of all nurses. Each organization pledged a willingness to underwrite the first Summit financially as well as provide active members for the planning committee. Each organization also publicized the conference to its membership using the communication methods with which they were familiar (brochures, e-mail, etc). This simplified the work of the planning committee.


Any statewide effort by busy professionals faces the obstacles of time and distance. In each round of planning, we had one in-person meeting to put names and faces together. After that, the work was completed by regularly scheduled conference calls. This allowed participation by those who lived outside the metropolitan area, as well as those working clinical shifts. Each of the organizational members took his/her responsibility to contribute seriously, and attendance on conference calls was high and each member of the planning committee actively contributed to the work. Additionally, the UMN-SoN provided support for marketing, designing and duplicating materials, staffing the conference, and providing continuing education credits and Internet registration. A wiki site for the conference planners to post minutes, documents, and others was provided by MINING. This was extremely helpful as it meant that all committee members had access to all the planning that had occurred. We were literally on the same page. It also reduced the stress of having to maintain and track our own files.


Another factor that contributed to a second successful 2009 Summit was building on suggestions from the 2008 Summit. The 2009 goals were to connect to the national initiative, highlight and celebrate local initiatives, and increase personal skill levels with technology. We invited two national speakers, Donna Dulong and Judy Murphy, to provide an update on the national efforts and describe how other sites implemented TIGER recommendations. Most of the day was spent on local initiatives such as the role of staff nurse councils in EHR governance, the chief information officer as a nursing role, and use of the EHR to address pressure ulcer prevention. The opportunity to provide a platform for nurses to make their work visible to the larger healthcare community was a primary benefit of our Summit. We saved a fun topic for the last presentation, Extreme Googling, which focused on the use of technology for managing one's life. This was appreciated by many in the audience who may work in informatics but are not able to keep up with all of the productivity tools available.


Typically, one would not expect that offering a conference in January in Minnesota would be successful. However, it does have advantages. Conference space is readily available, and there is not as much competition with other conferences. However, we were asking people to register over the holidays, and both years, the registrations began slowly and then flooded in during the last 2 weeks.


Looking forward, the planning committee will use the results of the brainstorming session to make plans. It would be easy to simply establish an annual conference. Judging from past experience, that would be popular with the community. But we would also like to take the feedback from the summit and find ways to work outside the framework of an annual conference to advance informatics and the TIGER vision. We have a committed group of volunteers, a large network of nursing professionals, and a small fund from two successful conferences. It is an opportunity that we do not want to waste.


CONTRIBUTORS TO THIS ISSUE[horizontal ellipsis]

Kathryn Hoyman, PhD, RN-C, clinical knowledge engineer at Fairview Health Services, Minneapolis, MN; Kim Zemke, MS, RN, clinical assistant professor, director of practice and professional development at the UMN-SoN, Minneapolis-St Paul; Julia Behrenbeck, MS, MPH, RN, patient education specialistinformation systems at the Mayo Clinic, Rochester, MN; and Bonnie Westra, PhD, RN, assistant professor and codirector, ICNP Center at the UMN-SoN, Minneapolis-St Paul.


Karen S. Martin, RN, MSN, FAAN, Health Care Consultant, Martin Associates, Omaha, NE.


Karen A. Monsen, RN, PhD, Assistant Professor, UMN-SoN, Minneapolis.


William Perry, MA, RN, is Adjunct Instructor, Wright State University, Dayton, OH.


Linda Q. Thede, PhD, RN-BC. Dr Thede is the editor of CIN Plus.