Written by: Crystal Maertens

Karen A. Monsen, PhD, RN, FAAN, Professor Emeritus at the University of Minnesota School of Nursing, gave Champ Software an early preview of her upcoming presentation for our Expert Webinar series. Dr. Monsen discussed the idea of enhancing public health through effective data management. Join our mailing list here to receive Expert Webinar invitations.

Dr. Monsen has had a long career working in the field of nursing informatics.¹ She has been an instrumental leader in the Omaha System community of practice. She has a wealth of knowledge and experience in data management and has helped countless health care agencies, Omaha System users, and public health workers improve their data documentation and data management, as well as educate on how that data can be leveraged in meaningful ways. 

In the sneak preview she supplied Champ Software, Dr. Monsen shared about her early career, researching and then educating herself on gathering meaningful data and putting it to use. She also shared the story of a successful project undertaken to gather and leverage meaningful data for the California Childhood Lead Poisoning Prevention Program. 

Dr. Monsen’s presentation covered:

1. Standardized data proves outcomes
2. Effective data management and why it is essential
3. Use Case: The CA Childhood Lead Poisoning Prevention Program adopts the Omaha System standardized taxonomy

Dr. Monsen perhaps best summarized her presentation when she said, “I’m here to share my insights about ways you can use your documentation data to enhance your reports and improve the health of your clients by helping you tell the story of your value and effectiveness!”

Standardized Data Proves Outcomes

Dr. Monsen’s presentation begins with a look at her early career and a moment that sparked her passion for meaningful data.

“Back in 1997, I was a program manager in a public health department. My director called me into her office one day and gave me marching orders. Her exact words were, ‘You will automate your nursing documentation and give me outcomes.’ 

“I went shopping for software and we went live in January of 1999 and never looked back at our cumbersome paper charting. One of the things that we discovered as we looked at our data a few months later was that we did have a way to show our impact. That was because we were using structured documentation that showed the progress of our clients after they received nursing visits. 

“The public health nurses and I used this documentation data to show our county administration that we were effectively changing the lives of high-risk clients who would otherwise continue to need more mandated services that would need to be paid by county tax dollars,” Dr. Monsen relayed.

After Dr. Monsen’s first foray into the world of standardized electronic documentation of data, she found a passion for discovering the best ways to collect and leverage valuable data to further public healthcare. In 2002, she obtained her master’s degree and in 2006, she finished her PhD. 

During this period, Dr. Monsen learned to leverage data in new ways, which included:

• Helping public health professionals analyze and publish their data
• Proving public health nursing interventions were effective
• Evaluating which interventions were most effective 
• Determining which interventions led to which improvements

Dr. Monsen learned the value of public health professionals and academic researchers working together to address public health problems. She also saw the value of teamwork and communication among colleagues across the continuum of care, locally, nationally, and even internationally, in understanding outcomes and evaluating the impact of their work. 

Dr. Monsen discovered the power and leverageability of standardized data to improve understanding, effectively direct resources, and prove that public health work improved outcomes. 

Effective Data Management and Why It’s Essential

Over the past couple of decades since Dr. Monsen first received the charge to bring her director outcomes, nearly everyone in public health and healthcare has adopted electronic documentation methods. More so than ever before, there is a wealth of data at public health professionals’ fingertips. But how can that data be effectively managed to be most useful?

In addition, collecting all the data is a lot of work! Dr. Monsen asked, “ What can we do to make all those clicks worth clicking? All those clicks and all that data should add up to something useful, right?” 

Effective data management means collecting and leveraging data for:

1. Informed decision-making
2. Strategic planning
3. Community well-being

“We want outcomes that we can show and share,” said Dr. Monsen. 

Use Case: The California Childhood Lead Poisoning Prevention Program

“We need a system that can give us a head start by looking upstream at how we generate the data. I’m excited and honored to share a recent real-life example that has been both visionary and successful,” Dr. Monsen said as she began to share the story of Dr. Taffany Hwang and her efforts for the California Childhood Lead Poisoning Prevention Program. 

Background

Dr. Monsen explained that a free-text public health nursing documentation system had been implemented to meet California state data requirements for the Childhood Lead Poisoning Prevention Program. Unfortunately, the free text documentation meant the data was not standardized. It was impossible to correctly evaluate the effectiveness of public health efforts to improve blood lead follow-up testing. “This unstandardized documentation made retrieving PHN assessments, interventions, and related outcomes impossible,” said Dr. Monsen.

Taffany Hwang, MSN, DNP, PHN, PNP-BC, MPH, is a Nurse Consultant III for the California Department of Public Health Childhood Lead Poisoning Prevention Branch. According to her bio on the Omaha System website, Dr. Hwang “is a board-certified Pediatric Nurse Practitioner with a dual MSN-MPH degree from Yale University and a DNP executive candidate at the Johns Hopkins School of Nursing.”

Dr. Hwang’s bio on the Omaha System website explains, “After a decade of practicing in primary and acute care pediatrics, she transitioned into a health policy and administration role at the California Department of Public Health… Taffany’s doctoral inquiry focuses on improving public health informatics, particularly collecting usable and meaningful public health interventions provided to the community by public health nurses and community health workers.”

Dr. Monsen summarized, “Dr. Hwang envisioned a better system that would be standardized, enable integration of childhood blood lead prevention data and provide quality data of outcome management and decision-making.”

After significant research, Dr. Hwang landed on the Omaha System standardized taxonomy as her choice for this project. Dr. Monsen shared, “It’s been around for several decades and has been used in public health for lots of programs. It was not until now that the blood-led world became aware of the Omaha System’s potential.” 

Dr. Hwang and her colleagues implemented the Omaha System into the electronic documentation the public health nurses were using for the Childhood Lead Poisoning Prevention Program. 

Showing Outcomes

Once data began to be documented in a standardized way using the Omaha System, it was possible to begin to track and quantify interventions and outcomes. Because everything was documented using the same language, data could be measured, quantified, and compared. In addition, it was possible to see change affected over time. The public health nurses could show their work.

The standardized documentation also allowed the creation of dashboards and graphics that could inform program administrators, decision-makers, and stakeholders how the program was mitigating childhood lead poisoning and the effectiveness of the evidence-based interventions being implemented. 

Dr. Monsen explained, “Within a few month’s time, they were able to quickly and easily obtain and reuse the data from their electronic documentation system to show adherence to protocols, as well as intervention tailoring to specific client needs, and to summarize the information—to show the impact of their services for several highly important healthcare problems.” 

Why the Omaha System?

“Dr. Hwang discovered that the Omaha System is a comprehensive, holistic lens for health and healthcare,” Dr. Monsen said. 

She continued, “You see, it makes a difference what perspective the data reveal. And you can’t get from data a perspective that isn’t there when you create the templates or forms that collect the data. The Omaha System was created to be comprehensive and to enable collection of data for all aspects of health, including the social determinants of health and the physical environment, as well as mental and physical health. It is holistic because it looks at all the things we might need to do to improve client outcomes and it also looks at various types of outcomes (knowledge, behavior, and status), not just morbidity or mortality statistics.”

Dr. Hwang also discovered:

• The Omaha System empowers users to collect meaningful data that can impact interventions and allow population outcome research.
• According to studies, standardized documentation improves documentation quality, the quality of care, outcomes,  and client satisfaction.
• Standardized documentation, such as the Omaha System, gives users a voice

“So, if we want data that enables us to hear our public health professionals and client voices, we need to make sure we can access it. And Dr. Hwang found this to be the most compelling reason of all to make a change in her program’s documentation practices,” Dr. Monsen shared. 

How Does the Omaha System Work?

There is power in the simplicity of the Omaha System. 

“What was surprising to Dr. Hwang was the simplicity of the Omaha System. It is intended to be simple and useful for all disciplines, which is one of the secrets to its success. Indeed, limiting our vocabulary to simple, defined terms increases our communication power. It actually helps us to share information more effectively, quickly, and easily. So, I think it’s worth a quick tour of several Omaha System concepts, just to show you how it’s put together and how easy it is to use,” said Dr. Monsen.

Dr. Monsen used the analogy of buckets of paint to describe the Omaha System organization: “These buckets, or what the Omaha System calls ‘problem concepts,’ are classified within four domains.”

The Four Domains

1. Environmental Domain
2. Psychosocial Domain
3. Physiological Domain
4. Health-Related Behaviors Domain

Dr. Monsen explained that each problem concept will exist in only one of the four domains: “The structure of concepts within the domains makes it easy to pull together the data once it’s been documented and see the big picture of whole-person health.” She went on to give examples of common health concerns (or problem concepts) and their corresponding domains. 

The Environmental Domain

Examples of problem concepts that would fall into the environmental domain include:

• Environmental lead: This falls under the residence problem.
• Income: Poverty, or, as Dr. Monsen described it, “one of the most important social determinants of health,” falls under the income problem.

Psychosocial Domain

Examples of problem concepts that would fall into the psychosocial domain include:

• Stress: This falls under the mental health problem category.
• Depression: This falls under the mental health problem category.
• Medical Neglect: This falls under the neglect problem.

Physiological Domain

Examples of problem concepts that would fall into the physiological domain include:

• Pain: This falls under the pain problem.
• High-Risk Pregnancy: This falls under the pregnancy problem.
• Dementia: This falls under the cognition problem.
• Trouble Walking: This falls under the neuro-musculoskeletal function problem. 
• High Blood Pressure: This falls under the circulation problem.

Health-Related Behaviors

• Obesity: This falls under the nutrition problem.
• Alcohol Abuse: This falls under the substance abuse problem.
• Insomnia: This falls under the sleep and rest patterns problem. 

“And so we see that everything about whole-person health fits together neatly when using the Omaha System,” Dr. Monsen explained. She continued, “These examples are just a taste of the well over 350 different signs and symptoms that help us to communicate using the Omaha System structure.”

The Problem Rating Scale

As each problem concept is documented, it is also rated on a Likert-style rating scale for 3 categories: knowledge, behavior, and status. 1 is the lowest rating and 5 is the highest rating. This rating scale allows users to see changes over time for problems.

“So, by choosing standardization with a simple problem list, we have exponentially increased the value of each of our clicks, which we can organize and manage coherently because of the Omaha System’s robust data structure. We document our interventions for each problem so it’s easy to organize these data as well,” Dr. Monsen summarized.

How the CA Childhood Lead Poisoning Prevention Program Used the Omaha System

Dr. Hwang and her colleagues chose 7 problem concepts from the Omaha System to use in the clinical pathway they created for the Childhood Lead Poisoning Prevention Program. “These were selected based on their definitions and their importance in reaching program goals,” Dr. Monsen said. 

The 7 problem concepts chosen were:

1. Healthcare Supervision
2. Growth and Development
3. Nutrition
4. Residence
5. Abuse
6. Neglect
7. Medication Regimen

The applicable problems are chosen for each client. Due to the program’s focus, the healthcare supervision problem and the growth and development problem would likely be documented for most clients. However, only the problems that are applicable to a particular client need to be assessed and documented for that client. 

During each nursing encounter, public health nurses would select the interventions that were completed for that encounter. There is an option to add a free-text note if additional clarification is needed, but for the purposes of standardization and meaningful data, that is not encouraged unless there are exceptional circumstances. 

“In this pathway, several interventions are pre-populated for each of the seven problems. Each intervention addresses a problem using a category and target combination together with a guide that is specific to the Childhood Lead Poisoning Prevention Program,” Dr. Monsen explained. 

“The categories describe the action of the intervention and the targets add specificity to the intervention. They are very logical and clear, making documentation of best practices easy and quick,” Dr. Monsen said.

Dr. Monsen provided some examples of the interventions for each problem.

Healthcare Supervision 

The healthcare supervision problem consists of 9 case management interventions, 2 surveillance interventions, and 2 teaching, guidance, and counseling interventions. 

Growth and Development 

The growth and development problem focuses on the client’s health and well-being. It has 13 interventions split evenly between case management, surveillance, teaching, guidance, and counseling.

Nutrition

The nutrition problem is not only meant to assess a child’s nutrition but also covers referrals to appropriate resources like WIC, etc. This problem has 6 interventions.

Residence

This problem has 9 interventions: 4 case management interventions, 4 surveillance interventions, and 1 teaching, guidance, and counseling intervention. This problem is meant to focus on the source of the lead and what is done to address it. 

Abuse

“The assessment of abuse is a core function of public health to ensure that children are safe in their homes,” Dr. Monsen explained. Referrals may be noted as well under this problem.

Neglect 

Similar to the abuse problem, the neglect problem is meant to document a core function of public health and note referrals as needed.

Medication Regimen

The medication regimen problem has 5 interventions, mostly for surveillance. This is where nurses document ongoing monitoring for adherence to chelation therapy (a therapy needed to treat elevated lead levels). 

Versatility of the Omaha System

The Omaha System allows users to add a problem or intervention as needed. In this way, pathways can be customized and additional interventions can be documented, making the Omaha System versatile. 

“If you find yourself always adding an intervention, you can update the pathway to make it available and easy to document for everyone. Remember, use only the problems you need. The problems give you the structure for your interventions and outcomes, and selective documentation gives you efficiency. Research shows that such structure makes documenting quicker and easier while leading to better outcomes,” Dr. Monsen said.

Conclusion

“Dr. Hwang and her colleagues found that data quality and practice quality go hand in hand. And that having a language to talk about problems, interventions, and outcomes makes our work and our impact transparent,” Dr. Monsen explained.

She continued, “You can see how attention to standardization and quality paid off for them as they were able to discuss in detail what they do as a program and what happens as a result. And now, they can slice and dice their data, looking at interventions and outcomes by type of client and program. 

“Their approach is spreading to other specialties, such as environmental health specialists, and potentially other jurisdictions as well. And having standardized data enables them to see, at a glance, where their efforts are concentrated in comparison to other programs and agencies.”

To read more about standardized terminology and, specifically, the Omaha System, check out Champ Software’s blog article, “Using Standardized Terminology to Document Whole-Person Health,” or our two-part article, “Social and Behavioral Determinants of Health Outcomes Data and Standardized Terminology.”

Citations

1. University of Minnesota. (n.d.). Karen A. Monsen | Institute for Health Informatics. Institute for Health Informatics. Retrieved July 31, 2024, from https://healthinformatics.umn.edu/staff/karen-monsen
2. The Omaha System. (2024). Board of Directors: The Omaha System. The Omaha System. Retrieved July 31, 2024, from https://www.omahasystem.org/boardofdirectors