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CARING
Vol. 21, No. 4 4th Quarter, 2006
ISSN: 1551-9104
Clinical Care Classification (CCC) System
Manual: A Guide to Nursing Documentation
[Book Review]
Reviewer: Marina Douglas, MS, RN
Principal, Beacon Healthcare Consulting
CARING is an organization advancing the delivery of quality
healthcare through the integration of informatics in practice,
education, administration and research with a focus on nursing.
DISCLAIMER: Content presented in the CARING Newsletter is not
intended as an endorsement for any particular vendor or product.
In This Issue:
Clinical Care Classification (CCC) System
Manual: A Guide to Nursing
Documentation [Book Review] . . . . . . . 1
President’s Message . . . . . . . . . . . . 1
CARING Member News . . . . . . . . . . . . 2
Upcoming Events . . . . . . . . . . . . . . .4
One Size Does Not Fit All:
An Initiative to Improve Pediatric
Patient Safety at Children’s
National Medical Center . . . . . . . .5
Natural Language Processing
and Understanding . . . . . . . . . . . .8
Collaborative Conference on
Nursing Informatics . . . . . . . . . . .9
Report on the TIGER Summit . . . . . .10
Central Florida CARING November
Meeting Report . . . . . . . . . . . . . 11
CARING–AMIA Luncheon . . . . . . . . . . .11
A Look into the New
CARING Website . . . . . . . . . . . . . . .12
©2006 The CARING Newsletter is produced with support
from:
Editor: Debra Derickson, MS, RN
Newsletter Team for this Issue:
Rose Almonte, Kathleen Crane, Sharon McGee, Susan Newbold,
Liberty Rovira, Jeanne Sewell, Susan Stanley, Cathy Turner,
Amy Walker
he 2006
TAMIA
conference
offered the
opportunity
to purchase a
valuable nursing informatics resource,
the Clinical Care Classification (CCC)
System Manual: A Guide to Nursing
Documentation from its Living Legend
author, Dr. Virginia Saba. The CCC
System Manual by Dr. Saba and
contributing authors documents the
history and progress of clinical
vocabularies and discusses the
importance and necessity of a structured
vocabulary for nursing practice. It
details the benefits of integrating a
structured vocabulary into automated
care planning as a means of identifying,
defining and quantifying nursing
practice. The CCC System Manual
provides the vocabulary components
needed to accomplish CCC structured
documentation in the care planning
process. Though not fully implemented
with a commercial product, CCC’s
structured vocabulary use with
automated clinical documentation
systems and automated care planning
seems highly plausible. The ongoing
efforts to maintain the CCC vocabulary
are outlined and the latest updates to the
vocabulary are listed in an Appendix.
The CCC System Manual is
presented in three parts, logically
providing the history and development
process as well as important discussions
of how the vocabulary can and has been
used in practice. The CCC system
contains 21 care components used to
By Virginia K. Saba, EdD, RN, FAAN, FACMI. Springer
Publishing Co., 2007.
US$35 ISBN 0-8261-0268-9
President’s Message
By Jerry Chamberlain, MS, RN
With the passing of each New Year, I have a
habit of looking back at past organizational
progress while also looking ahead at future plans
and endeavors. While we have accomplished a
tremendous amount of work over the past 12
months, I want to reserve that communication for
our annual meeting come this April. Instead, I
would like to take this opportunity to highlight a
few of the things CARING is planning for 2007.
High on the list of highlights is the upcoming
joint conference between ANIA and CARING on
April 27 and 28, 2007, in Las Vegas, NV. This is
the first time our two nursing informatics groups
are set to come together for a joint conference and I
couldn’t be more excited at the program we have
planned. From the opening keynote by our dynamic
colleague, Diane Skiba, PhD, to our 32 different
educational presentations and 20+ poster
presentations, an exhibit floor specifically designed
with nursing informatics in mind, and opportunities
at lunches, dinners, and social events to network
and connect – this conference is highly geared for
professional development and career growth. More
details can be found further in this newsletter, but
this is one event you do not want to miss!
I am equally pleased at our opportunity to work
with ANIA in the spirit of collaboration and shared
benefit. This project has brought together the
leadership boards of both organizations and
motivated us to find ways in which we can work
together for the benefit of all members. Looking
forward, 2007 is going to provide us with additional
opportunities to collaborate with other organizations
and I anticipate equally positive outcomes.
Increased focus and attention to CARING’s
website and web-based services are planned for
2007. In addition to an online member directory,
we have also implemented an online library – a
place to catalog and manage presentations, vendor
evaluation tools, teaching tips & tricks, and other
types of shared knowledge. Over the coming year,
CARING plans to provide ongoing enhancements
and content additions that will solidify our website
as a valuable resource for members.
CREATE 'n IMAGE
Graphic Design • Clorinda Haug
cmhaug@create-n-image.net • http://www.create-n-image.net
continued on page 2
continued on page 2

By Susan K Newbold, PhD RN-BC
FAAN FHIMSS
CARING Membership
CARING currently has over 1175 members
in 25 countries and 50 states.
Graduations
PhD
Laura Taylor, Ellicott City, MD.
Graduated May 2006, PhD, from
Catholic University of America,
Washington, DC. Her dissertation -
“Spouses of Living Kidney Donors: A
Grounded Theory Approach.”
Masters
Simone Frost, Takoma Park, MD.
Graduated December 2006, MSN,
Nursing Informatics, from the
University of Maryland School of
Nursing.
Karen E. Hunter, Alexander, NC.
Graduated May 2006, MSN, from
Duke University, Durham, NC.
Nancy Jo Thum, Sioux Falls, SD. MSN,
Nursing Informatics, from Vanderbilt
University School of Nursing,
Nashville, TN.
Post Masters Certificate
Catherine Fant, Big Cove Tannery, PA.
Post masters Certificate in Nursing
Informatics at University of Maryland
School of Nursing.
Certifications
Member News
Certification in Nursing Informatics,
American Nurses Credentialing
Center
Karen B. Lipshires, 2006, Tewksbury,
MA.
Linda S. McCauley, Laurel, MD.
Rosa Oliver, Clinton, MD.
Certified Professional in Healthcare
Information and Management
Systems, Healthcare Information and
Management Systems Society
Phyllis M. Bachand, Monee, IL.
Lynne MacAllister, Nashua, NH.
President’s Message – CARING 4th Quarter 2006 Newsletter
continued from Page 1
Continuing education and local networking has always remained a top priority
for CARING. In 2007, members will see additional offerings for local
networking while maintaining a national infrastructure. We have begun to host
regional meetings in Florida, California, and Arizona to assist regional
networking. Our next step is to connect the value of this local networking with the
opportunity of national education infrastructure and connections. CARING has set
up the building blocks to support this effort; 2007 will be our year to expand and
execute.
Lastly, each New Year brings the opportunity for new leadership and
involvement. CARING survives on the time and talent of our professional peers,
and if you have yet to contribute your own interests and expertise, I would ask
you to consider doing so now. You could organize or host a local CARING
meeting, you are welcomed and encouraged to assist with our national conference,
and you may want to serve as a formally elected board member. The value of
serving is rewarded ten-fold in professional growth and achievement. We are
going to need more leaders in 2007, so please consider bringing YOUR time and
YOUR talent to OUR group.
Thank you and Happy New Year.
– Jerry
Clinical Care Classification (CCC) System Manual:
A Guide to Nursing Documentation [Book Review]
continued from Page 1
classify and code clinical care. It associates 182 nursing diagnoses to an
appropriate care component. Further, clinicians can designate nursing actions
associated with each nursing diagnoses. The nursing actions are coded into the
following categories: Assess/Monitor; Care/Direct or Perform; Teach or Instruct;
and Manage or Refer. Expected Outcomes of care are coded as either to improve,
to stabilize or to support deterioration. Actual Outcomes are quantified as
improved, stabilized or deteriorated/died.
Section 1: Overview The author and a contributor, Kathleen McCormick,
bring the reader through the history of the CCC System. The timeline presented is
clear, assisting the reader to grasp the distillation of names and acronyms. This
section contains the background of the rigors and science used to create the
vocabulary and to continue its evolution over the past 15 years.
Section 2: Research, Integration and Evaluation This interesting section
provides examples of the successful use of the CCC System in various settings
and research projects. The reader gains an understanding of the interrelationship
between CCC and other vocabularies and standards such as the Unified Medical
Language System (UMLS), International Classification of Nursing Practice
(ICNP), Logical Observation Identifiers, Names and Codes (LOINC) and the
Health Level 7 (HL7) messaging standards. These examples sparked thoughts of
additional uses and research projects using the CCC system for clinical
documentation systems. Throughout the Manual, references are given.
Additionally, the last chapter in this section contains a bibliography of major
articles written about CCC – a wonderful surprise for future research uses.
continued on page 3
continued on page 3
CARING • Page 2

Clinical Care Classification (CCC) System Manual:
A Guide to Nursing Documentation [Book Review]
continued from Page 2
Section 3: Terminology Uses Three important chapters in this section are the
reason to purchase this manual. Chapter 13 proposes a costing model for nursing
care using the CCC System. The CCC System’s structured atomic data concepts
(i.e., each term having a unique meaning), facilitate automation of the costing
model and the retrieval of care data.* The costing model supports the nursing
process and the examples provided are easily followed. This chapter outlines CCC
as a mechanism for identifying, quantifying and determining nursing care costs.
Chapter 14 provides documentation strategies using CCC System in the context of
the nursing process as well as providing the CCC System in tables. The welldesigned
tables facilitate both the learning and use of CCC. In a personal
discussion with a sophomore nursing student, the tables were used to explain the
notion of a structured vocabulary and its use with computerized documentation.
The tables quickly conveyed the essentials of the CCC System concepts and
components to the student.
Summary
The Clinical Care Classification System Manual is a comprehensive tool for
understanding and implementing the use of structured clinical vocabulary – a goal
for every Informatics Nurse! It serves as both a reference for the background and
benefits of structured vocabularies, as well as a manual for implementing the CCC
System for the benefit of nursing care and nursing science.
*Reviewer’s Note: The many benefits of the identification and quantification of
nursing care will be accomplished by integrating the CCC System into
commercial automated care planning and clinical documentation software. Figure
1 provides an example of how CCC could be use in a traditional care planning
setting. Figure 2 depicts how CCC concepts may appear using a clinical
documentation methodology, such as PIE or APIE (Assessment, Problem,
Figure 1
Care Planning Example for a poorly controlled diabetic patient to manage
prescribed oral hypoglycemics coded using the CCC System
Coded Nursing
Diagnosis
G20.4
Coded Expected
Outcome
G20.4.1
Coded Intervention
H24.4.3
Coded Actual Outcome
G20.4.1
CCC Component
CCC Nursing Diagnoses
CCC Expected Outcome
CCC Nursing Intervention
CCC Nursing Actions
CCC Actual Outcome
G. Health Behavior Component
18. Health-Seeking Behavior Alteration
19. Home Maintenance alteration
20. Noncompliance
20.1 Noncompliance of Diagnostic Test
20.2 Noncompliance of Dietary Regimen
20.3 Noncompliance of Fluid Volume
20.4 Noncompliance of Medication Regimen
G20.4 Compliance with prescribed course of
medicinal substances.
Pt’s HbA1C level will improve
H. Medication Component
24.4 Medication Treatment – actions performed
to administer drugs or remedies
regardless of route
1. Assess/Monitor
2. Care/Direct or Perform
3. Teach or Instruct Medication Regimen
4. Manage or Refer
G20.4 Compliance with prescribed course of
medicinal substances.
1. Improve
2. Stabilize
3. Deteriorate
More Member News
Project Management Professional
(PMP) Credential
Charles Boicey, Mission Viejo, CA,
November 4, 2006. He is also working
on a Masters in Project Management at
Stevens in Hoboken.
Margaret Cox, Glenn Dale, MD,
January 2007.
Awards and Honors
Martha Dewey Bergren, Chicago, IL,
was accepted for the Omada Board
Leadership development program sponsored
by Sigma Theta Tau. The program
begins in March 2007 and ends in
February 2009.She will be assigned a
mentor and attend the Omada Institute,
held at the organization’s headquarters
in Indianapolis, from June 7-10, 2007.
http://www.nursingsociety.org/
programs/omada_main.html
Judy Murphy, West Allis, WI, was elected
to the AMIA Board of Directors for
another term from January 1, 2007
through December 31, 2009. Judy also
won the 2006 HIMSS Nursing
Informatics Leadership Award.
Carol Romano, Columbia, MD, was
honored during the University of
Maryland, Baltimore Founders week as
an “Illustrious Alumni.” See
http://founders.umaryland.edu/
alumni/romano.html
Robin Raiford, Coppell, TX, was honored
with the October 2006 “Spirit of
HIMSS” Award. She is Chair of the
Patient Safety and Quality Outcomes
Steering Committee, a liaison to the
HIMSS Advocacy and Public Policy
Steering Committee, and an exam
question writer for the CPHIMS certification
program. She also participates in
the Advocacy Legislation/Regulation
Review Work Group and the HIMSS
Electronic Health Record Vendors
Association. Robin will speak at
HIMSS07 as a CCHIT panelist discussing
“What It Means to the
Clinician at the Point of Care – Patient
Safety, Medication Management and
ePrescibing.”
continued on page 4
Page 3 • 4th Quarter 2006
continued on page 4

More Member News
Bobbie Stone, Freehold, NJ, was nominated
for Garden State Woman of the
Year for Garden State Woman
Magazine in the categories of
Healthcare and Women Owned
Business.
Betsy Weiner, Brentwood, TN, received
an Alumnae Award for Excellence in
Nursing Education from the University
of Kentucky and numerous other
awards for multimedia projects.
Presentations
2006 National League for Nursing
Technology Conference, (November 3,
2006). Online Teaching - Basic by
Jennifer Couvillon, New Orleans, LA,
Deana Molinari, and Susan K.
Newbold, Columbia, MD, University
of Maryland School of Nursing,
Baltimore, MD.
Publications
Nam-Ju Lee, New York, NY.
Bakken, S., Grullon-Figueroa, L.,
Izquierdo, R., Lee, N., Morin, P.,
Palmas, W., Teresi, J., Weinstock, R.
S., Shea, S. & Starren, J. (2006).
Research paper: development, validation,
and use of English and Spanish
versions of telemedicine satisfaction
and usefulness questionnaire. JAMIA,
13(6), 660-667.
Susan K. Newbold, Columbia, MD.
Newbold, S. K. and Dykes, P. (2006).
NI2006: The 9th international conference
on nursing informatics. CIN:
Computer, Informatics, Nursing, Vol.
24(6), 354-355.
Kathleen McCormick, Connie Delaney,
Patricia Brennan, Judith Effken,
Kendrick, Judy Murphy, Diane
Skiba, Judy Warren, Charlotte
Weaver, Betsy Weiner, and Bonnie
Westra. (2007). Guideposts to the
future - An agenda for nursing informatics.
JAMIA, 14(1), 19-24.
Nursing and Informatics for the 21st
Century won the HIMSS 2006 Book of
the Year Award. Editors are: Charlotte
Weaver (Kansas City, MO), Connie
White Delaney, Patrick Weber, and
Robyn L. Carr, (Auckland, NZ).
Clinical Care Classification (CCC) System Manual:
A Guide to Nursing Documentation [Book Review]
continued from Page 3
Intervention, Evaluation). Such integration must support the notion of ‘automagic’
for the end user. The ‘auto-magic’ terms refers to the thoughtful
profiling/configuring of a system by informatics nurses allowing computerization
of care data and its resulting outcomes for evidenced based practice and statistical
analysis while simultaneously supporting rapid online care planning and/or
documentation by clinicians. From the clinician’s perspective, the data and
statistics of the care they have provided are available from the computer as if by
magic.
Figure 2
Phrase Constructed Documentation with CCC
Potential snippets of ‘point & click’ clinical
documentation screens
Assessment
Neuro
GI
GU
CV
√ Endocrine -
Integument
Diabetes I
Diabetes II
Problem –
Hemoglobin A1C WNL
√ Hemoglobin A1C > normal
Hemoglobin A1C < normal
Intervention
√ Medication Treatment – provide teaching
Evaluation*
√ Hemoglobin A1C WNL
Hemoglobin A1C > normal
Hemoglobin A1C < normal
√
*Assumes there is improvement following teaching
CCC Coding within the configuration
files and tables of a Clinical
Documentation System
Assessment
G20 Health Behavior Component
Problem
G20.4 Non compliance w/ Medication Regimen
Intervention
H24.4 Medication Treatment - Instruct
Evaluation
G20.4.4 Non compliance w/ Medication Regimen
Improved
Editor’s Note: The Springer Publishing Company is offering a 10% discount on this book if you place your order directly from the publisher’s
customer service, identifying yourself as a CARING Newsletter subscriber. Discount code: CARING
(Disclaimer: A book review published in the CARING Newsletter does not convey endorsement or disapproval of the book or its contents
by CARING.)
Upcoming Events
March 9, 2007 2-4 pm
Central Florida CARING meeting at Florida Hospital i-Extend in Orlando, FL. For more
details, contact Amy Walker, (awalker625@aol.com).
March 16, 2007 4-7 pm
CARING meeting at the Embassy Suites Phoenix-Tempe Hotel, Phoenix, AZ.
Susan Newbold will speak on the topic of ‘Technology and the Nursing Shortage’. For
more details, contact Susan Newbold, (snewbold@umaryland.edu).
April 26 – 28, 2007
ANIA CARING Annual Conference, Las Vegas, Nevada. A collaborative event on the topic
of “Transforming the Future of Healthcare: Nursing Informatics 2007,” Earn up to 16.55
contact hours. See special ad this issue. Also check the CARING website
(www.caringonline.org) more details as they become available.
continued on page 5
CARING • Page 4

Photo courtesy of Karl Oyri
One Size Does Not Fit All: An Initiative to Improve Pediatric
Patient Safety at Children’s National Medical Center
By Susan Stanley, MSN, RN
Long ago in the land of babes, a techno-savvy group of nurses began
questioning the lack of well fitting armbands for the children. “Why do I have to
tape this giant band on my 3 kilogram baby? It always falls off anyway. I’ll just
tape it to the crib – that will work.”
his may sound like a fairy tale, but in reality, properly fitting identification (ID)
Tbands for pediatric patients is a challenge. In order to provide an age-specific
ID band, a team of clinicians at Children’s National Medical Center (CNMC) in
Washington, D.C. developed a task force to develop and implement point of care
access for pediatric ID bands. Sounds simple enough, right? Three arduous years
after the task force began its work, the staff at CNMC is on the verge of the actual
implementation. This article will outline the journey of the CNMC task force to
identify the desired elements and develop a concept of age-specific ID bands, and
the challenges encountered in this process. In a future article, the process of
implementation of the plan as well as lessons learned will be discussed.
Review of Current ID Band Processes
“To help reduce patient identification errors, most hospitals use patient ID
bands that can either be worn on the wrist or ankle” (“Technology in patient
safety,” 2005). At CNMC, the admissions department staff prints a “one size fits
all” ID band during patient registration, and in most cases, applies it to the child’s
wrist. In the Neonatal Intensive Care Unit (NICU), this band is unsuitable, forcing
the nurse or clerk to create a patient ID band by trimming the patient name,
medical record number, and account number from a pre-printed label and affixing
it to a soft band used for neonates. This soft band is then applied to the baby’s
extremity. In the presence of skin fragility, the ID band is secured to the bed. If,
for any reason, the ID band is removed, a new band is requested from admissions
via phone or fax and delivered to the unit with an expected time delay. Temporary
ID bands are available on the inpatient units that require trimming of a pre-printed
patient label to fit on the band. A frequent problem necessitating application of a
replacement band is contact with moisture from the patient directly or from
patient care activities that denigrate the visibility of the patient information on the
band needed for proper identification.
A series of interviews and scheduled demonstrations for band printers and ID
band designs led to selection of a vendor, Zebra Technologies. Our important
selection criteria included:
• Appropriate ID band size choices for pediatric patients
• ID band reprint capability at the point of care
• Ability to upgrade ID bands in the future to include Radio Frequency
Identification (RFID) without need to purchase brand new equipment.
• Thermal printing to maintain water proof integrity of printed ID Band
information
Designing the ID Band Elements
The design of the new band was one of the unexpected challenges for the task
force. Initially, the task force thought it wise to limit the information on the ID
band to patient name, medical record number, and encounter/account number
because a new band would not need to be generated if the patient’s attending
physician changed, or if the patient transferred to another
Page 5 • 4th Quarter 2006
continued on page 6
More Member News
Bytes of Interest
Debbie Harris, Columbia, MD, was featured
in the Howard County General
Hospital publication, Wellness Matters,
Vol.10, No. 4, Winter 2007 in an article
called, “Helping Hand gives a Head
Start.” Debbie is a volunteer for the
Community Action Council of Howard
County serving those in need.
Focus on Military members: CARING
has 38 members currently servicing in
the US Military service. Lori Frank
(Navy) and Angela Stone (Army) are
currently in Iraq. Saturnino “Tony”
Chavez (Army) is stationed in
Wurzburg, Germany. Margaret
Beaubein (Navy) is in Okinawa. We
thank our troops for serving within and
outside of the United States.
Karen S. Martin, Omaha, NE, reports
that an international conference, The
Omaha System: A Key to Practice,
Documentation, and Information
Management, will be held April 12-14,
2007 in Minneapolis-St. Paul, MN.
Details are posted on www.omaha
system.org, The Conference is cosponsored
by Martin Associates and the
University of Minnesota School of
Nursing.
Michael J. Sutter, Champaign, IL, was
interviewed and featured in a Health
Management Technology article,
“Clinical Systems are a ‘Go’ in Real
Life.” See http://www.healthmgt
tech.com and select the article from
the January 2007 issue.
Pauline Ellis, MPA, BSN, RN, COHN-S,
CLCP, Lake Ridge, VA died January
2007. She was an active member of
CARING from about 1998 to 2005.
She attended many meetings. In the
2002, Vol. 17 No, 2, CARING
Newsletter, Pauline penned a fascinating
account of Anthrax and the US
Postal service (USPS). She was an
Occupational Health Nurse at the
USPS in Washington, DC and used
information management tools to help
solve healthcare problems - a true
informatics nurse. She also presented
her story at a CARING meeting. Our
condolences go to her family.
Please send items for future newsletters
to: Susan K. Newbold,
snewbold@umaryland.edu

One Size Does Not Fit All:
An Initiative to Improve Pediatric Patient Safety at Children’s National Medical Center
continued from Page 5
room. This set of data would require
3 lines of text on the band. Next,
feedback was solicited from several
hospital departments to determine
any other required elements.
Additional requirements and
considerations were discovered
during this design phase:
• The Radiology and Imaging
department and the Operating
Room required the date of birth
(DOB) as an identifier to
differentiate same name and
similar name patients.
• Hospital administration required
inclusion of the CNMC Bear
logo
• Patient’s hyphenated names
would not fit on one line with
current limited print characters.
• Adding DOB and separating the
first and last names on 2
separate lines increased lines of
text on the band from 3 lines to
5 lines
• Barcodes for future use and
current technology
Barcode Technology
In order to prepare for future
barcode technology envisioned at
CNMC, the task force team realized
that addition of a barcode to the ID
band was needed. They proceeded to
learn more about barcode technology
than they ever expected. First
consideration was given to using a 2
dimensional barcode that would
contain the required patient data
elements. However, the equipment
currently used in Laboratory
Medicine department cannot read a 2
dimensional barcode. They use
barcode scanning of a linear, onedimensional
barcode on the received
specimen label. Because barcode
scanning for nursing and patient care
activities is not yet in use at CNMC, the team decided to begin with a linear, one
dimensional barcode that only captures the patient’s medical record number. In the
future, use of either 2-dimensional barcoding or RFID is anticipated and
Laboratory Medicine expects to upgrade their system accordingly.
Pilot Testing
Before advancing further in the project, a pilot test of proposed ID bands was
implemented for one week on an inpatient psychiatry unit, a surgical care unit,
and the NICU, to determine the integrity of the material, security of the adhesive
used, and ease of use by staff. The bands were pre-printed with “TEST BAND”
and were applied to the patient along with the official ID band in current use.
Informational letters were given to the parents to explain the project.
Next, a survey was conducted to elicit feedback on the piloted bands from
parents, staff, and patients. The feedback results included the following:
• The majority of the staff responses indicated approval of the new band. They
found it easy to use and apply. All staff responses showed preference of the
band to display the patient’s last name on the first line in bold font and that
the pediatric and adult bands be the same width. Three of the staff responses
suggested a bigger font size. One response suggested addition of a data
element - medical service.
• The adhesive area of the band was less secure for older children because
they could pick at the seam.
• Parent responses indicated the desire for a band that would fit their child
appropriately instead of attaching it to a crib or bed.
This feedback led to a modification of the design of the adhesive area by the
Figure 1
Serrated Slits in the
Band
Adhesive Overlap Area
vendor to replace the smooth
even seam with a serrated seam.
This seam format strengthens
adhesion as well deters a child
from lifting the entire edge. The
serrated seam in a jagged format
adheres more easily and will be
more difficult for the child to
lift. If the child picks at the
edges and lifts a seam, the
serrated portion will shred but
not lift the whole edge. See
Figure 1. The team also elected
to standardize the width of the
ID bands for neonatal, pediatric,
and adult as well as a band format to print the last name on the first line in bold
font. Figure 2 shows the new ID band design.
Figure 2
continued on page 7
CARING • Page 6

One Size Does Not Fit All:
An Initiative to Improve Pediatric Patient Safety at Children’s National Medical Center
continued from Page 6
Printing Logic
Over several months, the team worked with another vendor, Optio, to design
the software logic for printing the correct size band using data entered during the
registration process in admissions. Although using patient weight information
might be preferred for determining band size, the majority of the patients have not
been weighed prior to admission. Therefore, patient age was selected for use in
printing the initial ID band. Of course, the possibility exists a band based on age
will not fit the patient. Thus, the availability of printing a replacement ID band on
the unit at the discretion of the nursing staff was very important to the task force
charter. Three replacement ID band sizes were chosen for availability on the units:
SIZE LENGTH WIDTH AGE PARAMETER
Neonatal Band 6 inches 3/4 inch 0-30 days
Pediatric Band 7 inches 3/4 inch >30 days < 7 years
Adult Band 11 inches 3/4 inch > 7 years
The concept of reprinting patient care labels and face sheets on the inpatient
units from a clinical registration system is already established. With assistance
from the software vendor and CNMC’s information technology services (ITS)
staff, three additional files were
Figure 3
created in the clinical
registration system to represent
a neonatal, pediatric and adult
ID band. When needed, the new
ID band process will allow the
nurse to access the clinical
system on the unit, select the
patient, and request a reprint file
for the appropriate size ID band
plan after the patient is assessed
for the appropriate size.
Dedicated Zebra printers for the
ID bands will be located on
each inpatient care unit, as
shown in Figures 3 and 4.
Network Preparation
In order to implement the new ID
band process, preparation for printer
installation was required. This included
use of the local area network to retrieve
clinical information to formulate an ID
band, but an internal technology survey
revealed insufficient availability of data
cables and data jacks to connect to the
printers. With support from the ITS
Figure 4
department, the team developed a
plan for the location of each printer
and worked with a consulting
technology company to install the
data lines and drops. Each data jack
was activated and tested. The jacks
were clearly labeled for patient ID
printer and a road map of data jack
locations was provided as a resource
for the ITS department. In addition to
the need for additional cabling and
jacks, all ID band printers required an
IP address and description in order
for the network to locate the correct
printer. In a similar way, the printers
were added to a table in the clinical
registration system which identified
the location of the patient care unit
for point of care reprinting. The
network preparation phase of the
project used most of CNMC’s
technology personnel resources and
required more time than expected to
complete.
Next Steps
To prepare for implementation of
the new ID band process, the task
force will develop and execute an
educational plan for Nursing and
support staff to use the new software
and printers, begin actual use of the
new patient ID band process, and
evaluate its success. A follow up
discussion of these next steps and
lessons learned is planned for a future
issue of the CARING newsletter.
Reference:
Technology in patient safety: Using identification bands to
reduce patient identification errors. (2005, April). Joint
Commission Perspectives on Patient Safety, 5(4), 1-10.
Additional Reading:
Use of Color-Coded Patient Wristbands Creates Unnecessary
Risk. (2005, December). Patient Safety Authority, Vol 2,
Supplement 2. Retrieved February 15, 2007, from
http://www.psa.state.pa.us/psa/lib/psa/advisories/v2_s2_sup
__advisory_dec_14_2005.pdf
Page 7 • 4th Quarter 2006

Natural Language Processing and Understanding
‘Just because
it is free text
doesn’t mean
it has no
value.’
CARING educational event took
Aplace on October 3, 2006 at the
Skyline Complex in Falls Church,
VA. Participation was available via
Webex. Fifteen people registered to
attend in person, and 40 registered for
the Webex, including one from
Canada and one from Finland. The
session was titled “Introduction to
Natural Language Processing and
Understanding: Enter Clinical Data
the Way You Want, Capture
Clinical Data the Way You Need.”
Natural Language Processing” (NLP)
and Natural Language Understanding
(NLU) are emerging technologies that
continue to show promise for
extracting data from free text
documents.
CARING member Karen Doyle
with Dave Hellman and Dr.
James Flanagan from Language
and Computing developed this
session to explain some of the
basics of NLP and NLU
technologies. Definitions of the
associated terms include:
• Natural language: Any
language naturally used by
people – for example,
English, Spanish, or
Arabic; not a
programming language
such as BASIC, C ++, or
XML
• Natural Language
“Processing” (NLP): the
process of building
computational models for
understanding natural
language that is Machine
Dave Hellman
Readable
Input: natural language
text
Output: representation of the meaning of text
• Natural Language “Understanding” language (NLU): means knowing
what concepts a word or phrase stands for and how to link those concepts
together and is Machine Understandable
Input: natural language text
Output: interpretation of the infinite ways a human can express a concept
Use cases helped to demonstrate using NLP and NLU to transform the free text
from History and Physicals, Discharge Summaries, and other clinical notes into
discreet data elements that can:
• Improve patient safety and decision support applications
• Implement HL7 Clinical Document Architecture (CDA) representation.
• Populate a clinical data warehouse
• Support the billing and reimbursement process
The hour long session was very informative and provided a basic premise for
using an application that can capture and interpret data from free text entries.
This recorded Webinar is available for free viewing or downloading by
registering with your name and email address by using this link:
https://landc-events.webex.com/landc-events/onstage/g.php?
AT=VR&RecordingID=297314027
For more information, please contact Karen Doyle at karen@landcglobal.com.
Karen Doyle
CARING • Page 8

Page 9 • 4th Quarter 2006

Report on the TIGER Summit
IGER (Technology Informatics
TGuiding Educational Reform)
conducted an invitation-only summit
last October in Bethesda, Maryland.
The purpose of the summit was to
bring together leaders from the
nation’s nursing practice, education,
and informatics/technology
organizations, government agencies,
and other key stakeholders to develop
a 10-year vision, to articulate 3-year
local and global action plans, and to
affirm commitment by the participants
to carry out these action plans for
“transforming nursing practice and
education to better prepare nurses to
practice in an increasingly automated,
informatics-rich, and consumer-driven
health care environment.” (T.I.G.E.R.
Press Release, 2006). This
commitment means an effort towards
achieving 85% of their goals by Year
1 and 100% of their goals by Year 3
(T.I.G.E.R. Summary Report, 2006).
As planned, several documents were
produced to provide a report of the
summit work:
• The TIGER Press Release
• The TIGER Gallery Walk
Brochure
• The TIGER Final Report
• The 10-Year TIGER Vision with
Key Actions
The following link will allow you
access these documents after you
register on the TIGER summit
website. Registration will allow
TIGER to track the distribution of the
reports, and will provide email
updates on progress of the TIGER
initiative if you opt for this function.
http://app.quicksizzle.com//
Survey.aspx?SFID=26174
7 Key Pillars
At the summit, participants used
these seven focus areas or pillars to
inform their discussions around key
actions and success factors for each
pillar (T.I.G.E.R., 2006-2007):
1. Communication and Collaboration
• Communication Techniques and Methodologies
• Interdisciplinary Care
• Therapeutic Relationships and Technology
2. Education
• Integration of Informatics and Education
• Informatics Core Competencies
• Faculty Readiness (Barriers and Strengths)
• Generational Considerations
3. Informatics Design
• Intentionally Designed Informatics
• Ease of Use in Professional Workflow
• Design Considerations for Education and Learning Enhancement
4. Information Technology
• Electronic Health Record (EHR)
• Personal Health Record (PHR)
• System Interoperability
• Standards and Frameworks
• Technology Partners
5. Culture
• Culture Transformation
• Journey Milestones—steps on the journey of culture change
• Change Theory/Management
6. Management and Leadership
• Creating Shared Vision
• Courageous Leadership
• Direction and Support
7. Policy
• Organizational Policy (Local and Global)
• Governmental Policy (Local and Global)
Susan Newbold was CARING’s representative to the TIGER summit. She noted
that out of approximately 120 attendees, 30 were CARING members, who were
attending the summit as representatives from other groups. She will be keeping
CARING members informed about TIGER activities and how CARING will be
moving forward with an action plan.
Please visit http://www.umbc.edu/tiger and https://www.tigersummit.com for
more information about the TIGER Initiative and the TIGER Summit.
References:
T.I.G.E.R. Technology Informatics Guiding Educational Reform (TIGER), (2006-2007). 7 Key Pillars. Retrieved January 28, 2007, from
https://www.tigersummit.com/Pillars.html
T.I.G.E.R. Technology Informatics Guiding Educational Reform, (2006). TIGER SUMMIT, Summary Report: Evidence and informatics
transforming nursing, p 50.
T.I.G.E.R. Technology Informatics Guiding Educational Reform, (2006). 2006 TIGER SUMMIT, Press Release: Nation’s nursing and
informatics leaders gathering to create an actionable plan for bridging the quality chasm with information technology, p1.
CARING • Page 10

Central Florida CARING November Meeting Report
By Amy Walker, MS, RN
he Central Florida CARING group has grown to almost 30 members in the
Tshort 9 months since the first meeting. The November 10, 2006 meeting which
was held at South Seminole Community Hospital, welcomed 7 new attendees
along with 10 current members. A goal for 2007 is to meet every other month at
different locations. A meeting was scheduled for January 12 at Health First, and
another is scheduled for March 9 in Orlando. An announcement was made of the
upcoming Orlando WINI, Feb 16-18, 2007, sponsored by OptimizeIT Consulting
and Orlando Regional Healthcare System.
Link to registration: http://optimizeITconsulting.com/WINI.html.
Central Florida CARING members Cindy Kolombo RN,BC Senior Application
Analyst and Theresa Skinner RN,BC Application Analyst of Wuesthoff Health
System provided the educational session for this meeting titled “Multidisciplinary
Clinical Documentation of Plan of Care Using NIC/NOC.”
Wuesthoff Health System uses Meditech as the enterprise-wide software. The
presentation demonstrated the electronic, multidisciplinary use of Nursing
Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) in
a stroke patient that entered the system through the emergency department and the
subsequent admission to the Acute Stroke Unit at a Wuesthoff Medical Center.
The NIC/NOC care plans are set up with patient specific Problems, Outcomes,
and Interventions. Patient outcomes are assessed on admission, once a shift and at
discharge. The patient response to
interventions can be trended by the
outcome score received during the
specified time points.
David Barnhart, Wuesthoff CIO
states, “Cindy and Theresa are an
integral part to our Process
Improvement processes and
instrumental in implementing the
clinical documentation improvements
and developments.”
Wuesthoff Health System is located in Brevard County and is
the county’s leading comprehensive healthcare provider.
Wuesthoff Medical Center-Rockledge and Wuesthoff
Medical Center-Melbourne, both full service acute care
hospitals, and a full complement of health service affiliates,
comprise the system. Both Wuesthoff facilities received the
Joint Commission and Accreditation of Healthcare
Organizations (JCAHO) Certification in Disease
Management for Stroke. Wuesthoff Medical Center-
Rockledge was the first hospital in Florida and second in
the nation to receive a dual certification Gold Seal of
Approval from JCAHO for coronary artery disease care
and management for stroke.
CARING-AMIA Luncheon
ARING co-sponsored a
Cnetworking and educational
event during the American Medical
Informatics Association (AMIA)
conference in Washington, D.C. on
November 13, 2006. Two
prominent informatics nurses were
the featured presenters. Bonnie L.
Westra, PhD, RN, presented
“Wisdom From the Pioneers to
Create the Future.” She briefed
the audience about a current
project by the AMIA Nursing
Informatics Working Group to
document the pioneering efforts
and progress of nursing
informatics in the United States.
Many of these informatics nurse
pioneers have already been
interviewed and recorded on video and many more
interviews are planned. A book and video series are the
desired end product of this project. Virginia K. Saba,
EdD, RN, FAAN, FACMI, one of several true pioneers,
presented “Historical Perspectives of Nursing and the
Computer.” Her presentation was sprinkled with several
trips down memory lane, shared stories, and prompts to
bring a few other notable informatics nurse pioneers in
Dr. Bonnie Westra
Dr. Virginia Saba
the audience to come to the podium for
a few shared memories. Susan K.
Newbold, PhD, RN-BC, FANN,
FHIMSS, introduced the speakers as
well as provided a diversion for the
audience to participate in filling out a
quiz about nursing informatics,
CARING, and AMIA for the chance to
win a one-year subscription to
CARING.
Page 11 • 4th Quarter 2006

A Look into the New CARING Website
by Stephen W. Prouse MS, RN-BC
CARING Contacts
Newsletter
Debra Derickson, MS, RN
3774 Gunston Road
Alexandria, VA 22302
H: 703/578-0415
E-Mail: DebraDerickson@comcast.net
.
Membership
Susan K. Newbold, MS, RNBC, FAAN
6460 South Wind Circle
Columbia, MD 21044
H: 410/531-9244
E-Mail: snewbold@umaryland.edu
.
CARING Board of Directors:
Jerry Chamberlain
President
Patrick Shannon
Vice President, Program Planning
Amy Jacobs
Treasurer
Placidia Clark
Secretary
Debra Derickson
Newsletter Editor
Jason Windsor
Marketing Liaison
Susan Newbold
Membership, ANI Representative, E-list
Liberty Rovira
Web Committee Liaison
Stephen Prouse
CARING Webmaster
n mid 2006, the CARING web team completed the enhancement conversion of
Ithe CARING website at www.caringonline.org, allowing achievement of two
major goals:
1. Transform CARING’s web presence from a collection of flat files
manageable by one overarching administrator to a decentralized model
allowing for content components or modules to be managed by various
users.
2. Provide a real-time, searchable, and integrated membership directory.
The integrated membership database is the core component that drives access to
all other website features. In addition to serving as access control, it also enables
members to manage their own online profile, pay membership dues, subscribe or
unsubscribe from the e-list, and query other member profiles using the contact
center. Having members manage their own information and preferences also
improves the overall management and administration of the database online.
Other major content areas of the website include:
• Event Calendar – displays informatics-related events ranging from
networking dinners and meetings to the latest Weekend Immersion in
Nursing Informatics. It also provides other features such as online event
registration and functionality for exporting events to a personal calendar.
• Mobile Link – available only to current members actively logged into the
website, provides on-the-go access to the integrated members’ directory from
a web-enabled Personal Digital Assistant or Smart Phone.
• Bulletin Board – used to host a wide range of member submitted documents.
The goal of this content area is to create a collaborative repository of
documentation and discussions to support common projects and issues
within the disciplines of informatics. Members are encouraged to upload
non-proprietary content to any of the topical categories and are welcomed to
provide suggestions for additional categories. Any CARING member
interested in moderating a category should contact one of the board
members. Topical categories currently include:
– Industry Documents with sample and real-world content ranging from
wireless mobile device guidelines to Request For Proposal templates.
– Role descriptions
– Past meeting presentations.
• CARING Newsletters – current issues made available to members, and older
issues available to any visitor.
• Monthly Health News – a new member-supported section compiled by
CARING member Kathleen Kimmel. This section is a great example for
other members interested in maximizing the value of the website.
Future focus feature areas will include online polls to capture both simple and
complex questionnaires. Other areas considered for implementation include an
integrated e-list, really simple syndication (RSS) feeds, and podcasts. Ideas for a
simple questionnaire are welcome; just contact any CARING board member. In
addition, all visitors to the website are invited to provide feedback or comments
about the site in using the website feedback link under the “Actions” menu.
.
CARING Web site – Homepage
http://www.caringonline.org
CARING • Page 12