Clinical Information Database for Advanced Practice and Professional Registered

Nurses

Saint Louis University School of Nursing, August 12, 2007 (up-dated)

M. A. Lavin, ScD, RN, FAAN
Certified Adult Nurse Practitioner
[email protected]
©2008 Saint Louis University

Reference: This Clinical Information Database is an expanded and up-dated version of the one presented in:
Lavin, M.A. (2006). “Internet Tools for Advanced Nursing Practice” in Saba, V.K. & McCormick, K.A. (eds),
Essentials of Nursing Informatics. New York: McGraw-Hill, pp. 391 – 412.

Introduction
Clinical information databases and systems must be designed for system-wide and discipline-specific needs.
To meet discipline-specific needs, the design of clinical information databases and systems requires the
input of members of each involved discipline. The reason is that each discipline is alone responsible for its
knowledge base, practice, and standards of practice. Without this interdisciplinary approach to the
development of clinical information systems, the resultant system will be ineffective in addressing the patient
needs for which it is designed and inefficient.

Missouri is fortunate in that it possesses nationally and internationally recognized nurses and nurse
informaticists, who have helped shaped clinical information databases, and systems. This particular clinical
information database includes sites designed for the needs of registered professional and advanced practice
nurses. It also includes information on accessing clinically-related informatics standards organizations and
associations. Within each, there are nursing individuals and groups involved in the work of transitioning
nursing documentation into the electronic health record. Please do not hesitate to contact one or more
should you desire assistance within your own office, health center, or healthcare system.

Organization of the Database

This data bases contains content categorized as follows:

 Informatics Standards Organizations and Professional Associations

 Nursing Process

 Missouri Geriatric Initiatives

 Metasearch

 Search Engines/Databases

 Continuing Education

Scroll down, please.

Informatics Standards Organizations and Professional Associations

Information International Standards

Standards Organization (ISO), http://www.iso.ch/iso/en/CatalogueDetailPage.CatalogueDetail?CSNUMBER=33309
Organizations, specifically ISO 18104
http://www.iso.ch/iso/en/commcentre/isobulletin/articles/2003/pdf/terminology03-09.pdf%20
Terminology Reference Terminology
Models, and Model
ANA-
Recognized USDHHS National
http://www.ncvhs.hhs.gov/index.htm
Terminologies Committee on Vital and
Software Health Statistics
Products  USDHHS Background on Health Information Standards
http://www.hhs.gov/healthit/standards/background

HL7 (Health Level Seven) http://www.HL7.org

American Nurses
http://www.nursingworld.org/nidsec/
Association Nursing
[Includes ANA-recognized terminologies and software products]
Information & Data Set
Evaluation Center

Logical Observation http://www.regenstrief.org/loinc/

Identifiers Names and
Codes (LOINC)

http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=snomed_page
SNOMED Terminologies
and Solutions

Professional
Informatics
Associations
with their
Related
Nursing
Groups
______________________________________________________

Nursing Process
• Assessment
• Diagnosis/Treatment
• Outcomes/Evaluation
_______________________________________________________

Nursing Process
 Assessment
o Assessment Forms
o Miscellaneous Screening Tools
o Population-Based Assessment, example
o Risk Assessment
o Signs and Symptoms Manifestations

 Diagnosis/Treatment
o Calculators
o Bioterrorism/Emergency Preparedness
o Diseases/Conditions, pick lists
o Diseases, specific examples of
o Easy diagnosis
o Genomics
o Standardized Diagnosis Terminologies
o Unified Medical Language System
o Standardized Treatment Terminologies
o Nursing Care Plan Forms
o Practice/Treatment Guidelines
o Drug Management

 Outcomes/Evaluation
o Patient Safety
o Standardized Outcome Terminologies
o OASIS
o HEDIS

Nursing Process

Assessment Assessment Forms Hospital Soup

http://www.hospitalsoup.com/public/mr-ipa-mcch.pdf

Miscellaneous Screening Alcohol abuse and alcoholism

Tools National Institute of Alcohol Abuse and Alcoholism
www.niaaa.nih.gov

Domestic abuse, Vermont Department of Health

 Multiple assessment screening tools
Insert health topic desired in search box.
Wheeler Clinic Connecticut Clearinghouse,
www.ctclearinghouse.org

Population-Based Missouri Department of Health and Senior Citizens

Assessment, example http://www.dhss.mo.gov/DataAndStatisticalReports/index.html
(click on Data and then on MICA)

Risk Assessment Body Mass Index Calculator

National Heart, Lung and Blood Institute

Cancer Risk Tools

Harvard Center for Cancer Prevention. Risks

Coronary Heart Disease Risk Calculator

National Heart, Lung, and Blood Institute

Health risk calculators

University of Maryland Medicine

Signs and Symptoms National Library of Medicine

Manifestations MEDLINE Plus Health Information
http://medlineplus.gov/

Diagnosis/Treatment
Calculators Cornell University Medical College
Pediatric Critical Care Medicine

Manuel’s Web, Nursing calculators

Martindale’s Calculators Online Part I: Nutrition

Bioterrorism/ Emergency Preparedness and Response

Emergency Centers for Disease Control and Prevention
Preparedness

Center for Biosecurity

University of Pittsburgh
 Center for the Study of Bioterrorism and Emerging Infections
Saint Louis University

National Center for Biodefense

George Mason University

Disease/Conditions, Diseases and Conditions

pick lists http://www.cdc.gov/DiseasesConditions/

Disease/Conditions, Brain Attack: Stroke Scales

specific, examples of National Institute of Neurological Disorders and Stroke

New York Online Access to Health (NOAH)

http://www.noah-health.org/
in Spanish and English

Enter as search term: Ehlers-Danlos

OR enter: Lupus erythematosus

OR enter: Marfan

OR whatever disease entity needed

Easy Diagnosis http://easydiagnosis.com

Genomics Specific Genetic disorders

National Human Genome Research Institute

Genetic, Rare and Orphan Disease Resources Online

National Human Genome Research Institute
(very basic information)

Genonmics Search
Centers for Disease Control
Standardized Diagnosis Nursing Diagnosis Terminologies
Terminologies
 Clinical Care Classification (HHCC) System http://www.sabacare.com/

 NANDA International www.nanda.org

 Omaha System www.omahasystem.org

 Surgical Information Systems (SSM) Online

AORN’s Information Resource for Perioperative Leaders: Document Sharing Service
http://www.ssmonline.org/Documents/ListDocuments.asp

NANDA Diagnosis Submission Forms

 NANDA International www.nanda.org

 Concept Analysis Center

Network for Language in Nursing Knowledge Systems (NLINKS)

ICD-9-CM diagnosis codes and titles, new and revised

US Department of Centers of Health and Human Services
Centers for Disease Control and Prevention
Centers for Medicaid and Medicare Services
http://www.cms.hhs.gov/medlearn/icd9code.asp

ICF (International Classification of Functioning, Health, and Disabilities, published by WHO)

 http://www.cdc.gov/nchs/about/otheract/icd9/icfhome.htm,
Click on Disease Classification in left margin.
 Lumpkin, J.R. (2001). Report of the National Committee for Vital and Health Statistics:
Classifying and Reporting Functional Status National Committee for Vital and Health
Statistics, http://www.ncvhs.hhs.gov/010716rp.htm
 Health Care Financing Review
http://www.cms.hhs.gov/

Unified Medical Unified Medical Language System

Language System National Library of Medicine
Standardized treatment Nursing treatment terminologies
terminologies  Clinical Care Classification (Saba, 2003) www.sabacare.com

 Nursing Interventions Classification (NIC)

http://www.nursingworld.org/mods/archive/mod30/cec211.htm

 Omaha System (Martin, Elfrink & Monsen, 2001)

 Perioperative Nursing Data Set

Association of periOperative Registered Nursing (AORN)

 Gerontological Nursing Intervention Research Center

http://www.nursing.uiowa.edu/about_us/nursing_interventions/index.htm

 Center for Nursing Classification and Clinical Effectiveness

Includes: Nursing Interventions Classification
Classification
http://www.nursing.uiowa.edu/about_us/nursing_knowledge/clinical_effectiveness/index.htm

 Advanced Billing Concepts (ABC) Codes for Alternative

Medicine, Nursing and Other Integrative Healthcare
http://www.alternativelink.com/ali/home/

For FAQ to CMS, enter ABC Codes into CMS search box or access:

 Current Procedural Terminology (CPT) codes

American Medical Association

Practice/Treatment CDC - Centers for Disease Control and Prevention

Guidelines  Diseases and Conditions
 Sexually Transmitted Diseases Treatment Guidelines 2006
http://www.cdc.gov/std
 Tuberculosis
Core Curriculum on Tuberculosis http://www.cdc.gov/nchstp/tb/pubs/corecurr/

NCI - National Cancer Institute

 Treatment Cancer Treatment. Select from an A-Z listing. www.nci.nih.gov.

NGC
 National Guidelines Clearinghouse www.ngc.gov
 National Heart, Lung and Blood Institute, www.nhlbi.nih.gov

 National Asthma Education and Prevention Program Expert Panel Report 2:

Guidelines for the Diagnosis and Management of Asthma
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
 Guidelines for the Diagnosis and Management of Asthma—
Update on Selected Topics 2002
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
 Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III)
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
 Recommendations Regarding Public Screening for Measuring Blood Cholesterol
http://www.nhlbi.nih.gov/health/prof/heart/index.htm#chol
 High blood pressure guidelines: Joint National Commission (JNC) 7:
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
 Overweight and Obesity Clinical Guidelines
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

AAFP
 American Academy of Family Physicians, Clinical Recommendations

ADA
 American Diabetes Association, Clinical Recommendations

ACS
 American Cancer Society http://www.cancer.org/docroot/CRI/CRI_3.asp, to access
the professional site, you must first register free. To register, go to
http://www.cancer.org/docroot/home/index.asp?level=0 and click on “I want more
information and then select “professionals from the drop down menu

CDC
 The Centers for Disease Control and Prevention
 Vaccines and Immunizations: http://www.cdc.gov/vaccines
 More Information on Vaccines

DEA
 Drug Enforcement Agency, www.dea.gov
Drug Management  Diversion Control: Drugs and Chemicals of Concern
 FDA
 Food and Drug Administration www.fda.gov
 Center for Drug Research and Evaluation, Food and Drug Administration
 The FDA Safety Information and Adverse Event Reporting Program, Medwatch
 Adverse Event and Product Problem Forms, Medwatch, Food and Drug Administration
 VAERS (Vaccine Adverse Event Reporting System) http://www.vaers.hhs.gov/

NLM
 National Library of Medicine
 Clinical Alerts Database, National Library of Medicine www.pubmed.gov
or http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

NIH
 National Institutes of Health www.nih.gov and scroll down to the Institute you desire
to access.

Medscape www.medscape.com
Subscribe free and then click on “drug information after inserting drug name in search box.

Rxlist www.rxlist.com

Family Practice Notebook (Provides link to 2AIDA 2001 insulin dosing simulations)
http://www.fpnotebook.com/END135.htm

Outcomes/Evaluation

Patient Safety

 Agency for Healthcare Research and Quality (AHRQ), Web Morbidity and Mortality Rounds

 Patient safety page, Medscape.com and log in and then access the Patient Safety page.

 Institute for Healthcare Improvement

Standardized Outcome Terminologies

 Center for Nursing Classification and Clinical Effectiveness

Includes: Nursing Interventions Classification and Nursing Outcomes
Classification
http://www.nursing.uiowa.edu/about_us/nursing_knowledge/clinical_effectiveness/index.htm
  International Nursing Minimum Data Set (NMDS)
http://www.inmds.org/PostNuke/html/index.php

 Minimum Data Set (MDS) Information Site, Centers for Medicare and Medicaid Services

 MDS Quality Measures, Centers for Medicare and Medicaid Services

http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp#TopOfPage

 Outcomes Assessment Information Set (OASIS), Centers for Medicare and Medicaid Services
http://www.cms.hhs.gov/OASIS

 Health Plan Employer Data and Information Set (HEDIS®), National Committee for Quality Assurance (NCQA)
2007 HEDIS measures http://web.ncqa.org/tabid/59/Default.aspx

Example: Missouri 2006 Consumers’ Guide

Commercial: http://www.dhss.mo.gov/ManagedCare/com_06.pdf
MC+: http://www.dhss.mo.gov/ManagedCare/mcaid_06.pdf
Medicare: http://www.dhss.mo.gov/ManagedCare/mdcre_06.pdf

Example: Select list of HEDIS measures used by Blue Choice

http://www.opm.gov/insure/health/hedis2002/9G.asp

Example: Minnesota Department of Health, HEDIS Reports

Chart or Medical Record Audits

 Example: Ophthalmic Mutual Insurance Company (OMIC),Medical Record Audit

Biostatistical measurement and analysis

 Centers for Disease Control, Epidemiologic analysis software

 Centers for Disease Control and Prevention,

Qualitative data creation, management, and analysis software

 Centers for Disease Control and Prevention,

Qualitative database software
  Statistical test calculators: http://www.ifigure.com/math/stat/testing.htm

 America Online,
Free biostatistical software and biostatistical tests online
http://statpages.org

 College of St. Benedict/St. John’s University,

Student’s t test calculator http://www.physics.csbsju.edu/stats/t-test.html

Missouri Geriatric Initiatives

Aging Successfully and Glidepath Tools

http://medschool.slu.edu/agingsuccessfully/index.phtml?page=glidepathintroduction

 Geriatric Screening Tools

http://medschool.slu.edu/agingsuccessfully/index.phtml?page=healthsurveys

 Clinical Glidepath® Tools Sampler per Acrobat Reader

http://medschool.slu.edu/agingsuccessfully/index.phtml?page=healthsurveys

Quality Improvement Program for Missouri

http://www.nursinghomehelp.org/

Center for Eldercare Rehabilitation and Technology

Includes a variety of evidence-based and knowledge-based resources
http://eldertech.missouri.edu/links.php

Metasearch, Continuing Education and Information Standards Organizations

Meta-search Engine Providers

 EMetasearch http://emetasearch.com

Meta-search search engines

 National Library of Medicine Gatewary http://gateway.nlm.nih.gov/gw/Cmd
 Ithaki http://www.ithaki.net/indexu.htm
 Metacrawler, www.metacrawler.com
Meta-search standards
 National Information Standards Organization
http://www.niso.org/committees/MetaSearch-info.html

Public Domain Search Engines/Databases

 MEDLINE, National Library of Medicine, www.pubmed.gov, click on Limits, then click on Subset drop
down menu, then click on MEDLINE
 PubMed, National Library of Medicine, www.pubmed.gov
 PubMed’s Clinical Queries, National Library of Medicine,
Access in the left hand margin of the pubmed.gov homepage or click on
http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.html
 PubMed’s Special Queries, National Library of Medicine
Access in the left hand margin of the pubmed.gov homepage or click on
http://www.nlm.nih.gov/bsd/special_queries.html
 NLINKS Research Center databases
Network for Language in Nursing Knowledge Systems
http://www.nlinks.org/research_main.phtml

Continuing Education

 CDC
http://www.cdc.gov/search.do?action=search&queryText=continuing+education&x=17&y=8

 University of North Carolina – Chapel Hill http://www.med.unc.edu/cme/

 Medscape. Subscribe free and sign up for “nurses” page.
There you will find an array of continuing education pages.
Plus, you have access to other pages as well, e.g., infectious disease, cardiovascular, endocrine and their
related CME’s. Medscape.com is an approved ANCC site. www.medscape.com
 National Council of State Boards of Nursing, www.ncsbn.org and
enter continuing education courses in the search box
 CDC TB Continuing Education http://www.cdc.gov/nchstp/tb/pubs/corecurr/
 Cancer continuing education. Scroll down left hand margin for CME.
http://www.cancer.org/docroot/HOME/pro/pro_0.asp

The End