Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. C. Content Coverage Provided for Terms Within the Minimum Data Set

05/01/2003

Table 5 compares the content coverage of SNOMED CT, ICF, and ICNP for all terms within the MDS. Again, as expected SNOMED CT provided the most complete coverage of the three coding systems reviewed in this study.

A few comparisons are of particular interest. First ICNP provided relatively complete coverage of interventions compared to ICF. This is very consistent with the focus of the ICF on providing a profile of functioning and disability, while the emphasis of the ICNP is on interventions provided by nurses as well as patient assessments. Similarly, the content coverage of administrative terms is more extensive in the ICNP than in the ICF.

TABLE 1. A Comparison of Recommended Data Elements to Infer Quality of Care for Persons with Pressure Ulcers/At Risk for Pressure Ulcers
  Pressure Ulcers:
ACOVE
Pressure Ulcers:
Domain Expert
Pressure Ulsers:
MDS Quality Measure
Targeted history and physical Risk assessment
  • Risk for decreased tissue perfusion: Tobacco use and CABG procedure
  • Radiation treatment
  • History of ulcers
  • History of hospital stays
  • Surgical treatments: Surgical flap
  • At risk for developing pressure ulcers
  • High risk for pressure ulcers
  • Risk assessment tools
  • Braden scale
  • Norton scale
  • Skin inspection
 
Treatment for condition
  • Preventive interventions
  • Nutritional interventions
  • Management
  • Debridement
  • Cleansing
  • Topical dressing
  • Management
  • If at risk, then repositioning and pressure reduction for tissue loads
  • If at risk and malnourished, then nutritional intervention
  • If > stage 2, no topical antiseptic
  • If full thickness sacral or trochenteric with necrotic debris or eschar, then debride
  • If clean full-thickness or partial-thickness, then topical dressing
  • If s/s of infection with no other cause, then debride within 12 hours, tissue biopsy or needle aspiration for culture and sensitivity within 12 hours
  • Ulcer care plan
  • Application of dressings
  • Clean dry dressings
  • Dressings that keep ulcer bed continuously moist
  • Protective dressings
  • Cleanse wound
  • Mild cleansing agent
  • Whirlpool treatment
  • Wet to dry dressings
  • Debridement
  • Topical debriding agents
  • Autolytic debridement
  • Enzymatic debridement
  • Mechanical debridement
  • Wound irrigation
  • Foam
  • Gel
  • Growth factors
  • Hormones
  • Hyperbaric oxygen
  • Infrared ultraviolet
  • Hydrotherapy
  • Normal saline
  • Topical agents
  • Topical aminoglycoside treatment
  • Topical antibiotics
  • Topical treatment with iodine containing agents
  • Avoid massage over bony prominences
  • Moisturizers
  • Luricants (corn starch and cream)
  • Electrical stimulation therapy
  • Low energy laser irradiation
  • Assisted oral feeding
  • Oral supplements
  • Devices that totally relieve pressure
  • Distribution of weight
  • Proper postural alignment
  • Characteristics of support surfaces
  • Dynamic support surface
  • Low air loss bed
  • Pressure relief
  • Pressure reducing beds
  • Pressure reducing mattresses
  • Pressure reducing overlays
  • Maintain position in bed or chair
  • Nutritional management
  • Aggressive nutritional interventions
  • Air fluidized beds
  • Plan of nutritional support
  • Patient education
  • Repositioning schedule
  • Surgical flap
  • Postoperative viability of the surgical site
  • Evaluate adequacy of treatment
 
Assessments
  • Risk assessment
  • Evaluation
  • If unable to reposition self, then risk assessment for pressure ulcers
  • If pressure ulcer, assess for location, depth, stage, size, presence of necrotic tissue
  • If partial thickness pressure ulcer and no improvement after 2 weeks then assess appropriateness of tx plan
  • Age, gender
  • Cognition: Comatose, Cognitive skill, Distracted, Awareness, Restlessness, Lethargy, Mental function, Altered level of consciousness, Depression score, Mental status
  • Speech, Verbal responses
  • Ability to move: Bed mobility, Bed bound, Chair bound, Transfer ability, Walking ability, Locomotion, Dressing ability, Motion of: neck, arm, hand, leg, foot; ADL function, Activities of daily living, Restraint use, Body control, Mobility device, Difficulty with repositioning, Impaired ability to reposition, Immobility, Spinal cord injury, Physical status
  • Nutrition: Eating ability, Nutritional intake, Oral/nutritional status, Oral problems, Oral nutritional supplements, Enteral feeding, Modular products, Vitamin/mineral supplements, Weight loss, BMI, Poor meal intake, Dietary intake, Albumin, Nitrogen balance, Nutritional status, Dietary intake of protein, Dietary intake of calories, Malnutrition, Nutrition screening, Nutritional assessment
  • Risk for moisture exposure: Toilet use, personal hygiene, bathing, bowel incontinence, bladder incontinence, Toilet use, Briefs, Protective padding, Underpads, Skin hydration
  • Recurrence of pressure ulcer
  • Location of pressure ulcer
  • Stage of pressure ulcer
  • Ulcer healing
  • Friction injuries
  • Bed linen to move
  • Lifting devices
  • Minimize force and friction
  • Positioning devices
  • Transferring support
  • Turning techniques
  • Risk for delayed healing
  • Bony prominences
  • Infections
  • Pressure ulcer
  • Risk adjustment: Impaired transfer or bed mobility
    OR
    Risk adjustment: Comatose
  • Malnutrition
  • End stage disease


TABLE 2. A Comparison of Recommended Data Elements to Infer Quality of Care for Persons with Chronic Pain
  Chronic Pain Management:
ACOVE
Chronic Pain:
Domain Expert
Chronic Pain:
MDS Quality Measure
Targeted history and physical
  • If newly reported chronic pain condition then history and physical within 1 month
  • If treated with NSAIDs, check history to peptic ulcer disease
  • If history of peptic ulcer disease, justify NSAID use
  • If treatment with opioids, then bowel regimen/treatment
  • Presence of diagnoses known to be painful: osteoarthritis, low back pain, fibromyalgia, spinal stenosis, post-herpetic neuralgia, peripheral neuropathy, myofascial pain syndromes, vasogenic claudication, phantom lim pain, headaches, vasculitic pain syndromes, osteoporosis with fractures, cancer, contractures, peripheral vascular disease, rheumatoid arthritis
  • When starts, what started it, what makes it better, what makes it worse
 
Treatment for condition
  • If newly reported chronic pain condition then offer treatment
  • Acetominophen for OA
  • NSAIDs for OA
  • Opioids
  • Avoid meperidine
  • Pain intensity monitoring
  • Appropriate use of medications
  • Appropriate use of non-pharmacologic interventions
  • Acetominophen for OA
  • NSAIDs for OA
  • Opioids
  • Avoid meperidine
 
Assessments
  • If treated, then assess for response within 6 months
  • Depression
  • Palliative care
  • Side effects of new medications
  • Education concerning medication side effects
  • Osteoarthritis
  • Dementia
  • Delirium
  • Pain Scales: Numeric estimate (0-100); Verbal descriptors: no pain, moderate, severe, excruciating, worst pain possible, most intense pain imaginable; Faces pain scale; Pain map; McGill pain questionnaire
  • Pain Behaviors: Facial (wrinkled forehead, tightly closed eyes, grimacing, frowning); Nonverbal behavior (bracing, rubbing, guarding); Vocalizations (crying, yelling, groaning, moaning)
  • Nonverbal indicators of discomfort: Aggressive, crying, fearful, negative vocalization, noisy respirations, pacing, repetitive, restlessness, rocking, confusion irritability, increased activity, withdrawal, tense, calling out, grunting, knees pulled up; Other changes in usual activities or behavior patterns/routines
  • Impact of pain on quality of life outcomes
  • Physical function, sleep, appetite, interpersonal relationships/ interactions with others, mood (anxiety, depression), mental status (ability to think clearly/ concentration/confusion), energy/ fatigue
  • Moderate pain at least daily
  • Horrible/ excruciating pain at any frequency
  • Independence in decision making


TABLE 3. A Comparison of Recommended Data Elements to Infer Quality of Care for Persons with Urinary Incontinence
  Urinary Incontinence:
ACOVE
Urinary Incontinence:
Domain Expert
Urinary Incontinence:
MDS Quality Measure
Targeted history and physical
  • If new or persists >1 month, then targeted hx: Voiding characteristics; Ability to get to toilet; Previous tx for incontinence; Importance of problem to pt.; Mental status
  • If new or persists >1 month, then target physical: Rectal exam; Genital system exam
  • If new or persists >1 month, then dipstick ua and post-void residual
  • If newly discovered overflow incontinence and indwelling catheter used, documentation, that not candidate for other interventions as result of physical or mental impairments or tx preference
  • Characteristics of voiding and non-invasive bladder diagnosis
  • Ability to toilet
  • Prior treatment for incontinence
  • Importance of problem to patient
  • Mental status exam
  • Rectal exam to exclude fecal impaction
  • Skin exam to evaluate skin problems associated with urinary incontinence
  • Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)
 
Treatment for condition
  • If cognitively intact without hematuria or high post void residual, then behavioral therapy
  • If surgery or periuretheral injections, then cystometry before procedure
  • If female with stress incontinence caused by sphincter deficiency, then surgery is sling or artificial sphincter procedure
  • Behavioral therapies
  • Prompted toileting
  • Prompted voiding
  • Scheduled toileting
  • Timed voiding
 
Assessments  
  • MDS recal scale, MDS item B3, or Cognitive performance scale derived from MDS items
  • Frequency of incontinence
  • Status of incontinence: day and night
  • Symptoms on urination
  • Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)
  • Mobility problems on MDS and provider notes
  • Toileting responsiveness assessments: How often person voids when prompted on a routine basis
  • Voiding record
  • Non-invasive diagnoses of bladder function
  • Urodynamic analyses of bladder functioning (for select diagnoses)
  • Lab reports
  • Primary care notes
  • Control of urinary bladder function or continence programs, if employed
  • Risk adjustment: Severe cognitive impairment
  • Totally ADL dependent in mobility
  • Total dependence in ADL self-performance


TABLE 4. Content Coverage Provided by Selected Coding Systems for Terms Related to Three Domains of Quality: Chronic Pain, Pressure Ulcers, and Urinary Incontinence
Terms Provided by Domain Experts MDS
Coverage of Terms
SNOMED CT
Coverage of Terms
ICF
Coverage of Terms
ICNP
Coverage of Terms
Complete
Match1
Partial
Match2
No
Match
Complete
Match1
Partial
Match2
No
Match
Complete
Match1
Partial
Match2
No
Match
Complete
Match1
Partial
Match2
No
Match
PRESSURE ULCERS
(n=179 terms)
70% -- 30% 77% 10% 13% 18% 37% 47% 16% 24% 60%
   Administrative
   Information
   (n=5 terms)
100% -- -- 100% -- -- -- 20% -- -- -- 100%
   Resident
   History
   (n=10 terms)
80% -- 20% 80% -- 20% -- 10% 90% 20% 40% 40%
   Assessments
   (n=82 terms)
75% -- 25% 85% 13% 2% 12% 50% 38% 21% 28% 50%
   Treatments
   (n=82 terms)
50% 21% 29% 90% 10% -- -- -- -- 25% 40% 35%
CHRONIC PAIN
(n=79 terms)
8% 8% 84% 92% 8% -- 4% 9% 87% 3% 5% 96%
   Administrative
   Information
                       
   Resident
   History
   (n=19 terms)
26% 16% 58% 94% 5% -- -- 26% 73% 5% 10% 84%
   Assessments
   (n=53 terms)
9% 13% 77% 84% 16% -- 6% 17% 77% 2% 2% 96%
   Treatments
   (n=7 terms)
-- -- 100% 100% -- -- -- -- 100% 15% -- 85%
URINARY INCONTINENCE
(n=28 terms)
8% 8% 84% 95% 5% -- 4% 50% 46% 4% 46% 50%
   Administrative
   Information
   (n=5 terms)
                       
   Resident
   History
   (n=2 terms)
-- -- 100% 100% -- -- -- 50% 50% -- 50% 50%
   Assessments
   (n=20 terms)
15% 15% 70% 85% 15% -- 5% 50% 45% 5% 50% 45%
   Treatments
   (n=6 terms)
-- 15% 85% 100% -- -- -- 50% 50% -- -- 100%
  1. Complete match indicates a lexical match and/or synonyms (e.g. "ability to toilet" and "ability to use toilet")
  2. Partial match includes either of the following
    • terms with a broader or narrower conceptual meaning (e.g., the ICF code of "Weight maintenance function" has a broader conceptual meaning than the domain expert term of "weight loss")
    • coverage of some but not all concepts in the target term (e.g., the ICNP code of "nursing home" provides partial coverage of the MDS term "prior stay at this nursing home")


TABLE 5. Content Coverage Provided by Selected Coding Systems for All Terms Within the Minimum Data Set (MDS)
Terms Within the MDS SNOMED CT
Coverage of Terms
ICF
Coverage of Terms
ICNP
Coverage of Terms
Complete
Match1
Partial
Match2
Complete
Match1
Partial
Match2
Complete
Match1
Partial
Match2
(n=628 terms) 46% 45% 2% 39% 12% 50%
Administrative Information (n=87) 20% 71% -- 8% 1% 38%
Resident History (n=143) 89% 7% -- 40% 1% 53%
Assessments (n=262) 29% 66% 4% 58% 20% 53%
Treatments (n=93) 63% 33% -- 31% 20% 57%
Other3 (n=43) 40% 37% -- 7% 2% 38%
  1. Complete match indicates a lexical match and/or synonyms (e.g. "ability to toilet" and "ability to use toilet")
  2. Partial match includes either of the following
    • terms with a broader or narrower conceptual meaning (e.g., the ICF code of "Weight maintenance function" has a broader conceptual meaning than the domain expert term of "weight loss")
    • coverage of some but not all concepts in the target term (e.g., the ICNP code of "nursing home" provides partial coverage of the MDS term "prior stay at this nursing home")
  3. "Other" includes terms such as provider information (e.g., signature), quantities (e.g., 1 to 500 cc/day), and available activities (e.g., cards/other games)

A discussion of these results follows in the next section.


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