Kitsap Public Health District serves the population of Kitsap County, Washington (about 254,000 people, as of the 2013 census).

Kitsap Public Health District has been a client of Champ Software since 2005.

At a Champ Software Expert Webinar held in April, 2016, Suzanne Plemmons, MN, RN, PHCNS-BC, and then-Community Health Director (since retired), along with Nancy Acosta, RN, Home Visiting Nurse with Kitsap’s Nurse Family Partnership (NFP) program, co-presented with Karen S. Martin, RN, MSN, FAAN, Health Care Consultant, Martin Associates.

They shared Kitsap Public Health District’s success in measuring health outcomes using the Omaha System and Champ Software’s Nightingale Notes EHR.

“The Omaha System is a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care… and includes an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an evaluation component (Problem Rating Scale for Outcomes).”1


Nancy Acosta described a little of Kitsap Public Health District’s background, “Around 2003, we talked about the need for some computer documentation… We were hoping to find better measures of our outcomes.

“We also wanted… the nurses in the field to be faster, [as well as our support staff and our epidemiology staff].” In this endeavor, Kitsap County developed an interest in the Omaha System and sent a team of five people to the 2005 Omaha System International Conference.”

Based on the information they gathered at that conference, Kitsap County developed an Omaha System training and implementation plan for their agency. “We studied on our own, we met in groups, and we practiced on paper,” Nancy shared.

Later that year, an interdisciplinary team worked to develop an RFP, then select and purchase an EHR.

Kitsap County chose an EHR product from Champ Software, a legacy, server-based product.

“We had a one day training with Karen Martin, we had onsite training with Champ staff for our server-based system, and then we went live in March, 2006.

“We decided we needed ongoing inter-rater reliability,” Nancy detailed.

To accomplish this, Kitsap County strove to continue ongoing Knowledge, Behavior, and Status (KBS) training each month.

KBS is part of the Omaha System’s Problem Rating Scale for Outcomes; a method to evaluate client progress using a Likert-type scale to measure the client’s Knowledge, Behavior, and Status.2

In August of 2010, Kitsap County graduated to Nightingale Notes, the web-based EHR solution Champ Software debuted in 2009, offering charting that was developed from the ground up using the Omaha System standardized terminology.

In recent years, Nancy shares that Kitsap County hasn’t stopped their pursuit of expertise in use of the Omaha System or their goal of inter-rater reliability, “We continued to use our Minnesota User Group as a resource and we used our Nightingale Notes webinars when [those] came around.

“And we’ve continued to send at least one staff person to the Omaha System International Conference every two years.”

Successfully Measuring Outcomes

All of that hard work has paid off in the form of outcome reports that Kitsap Public Health District uses to describe their population and measure client outcomes.

“We use standardized reports all the time. We use them every day when we are reporting to our funders and when writing reports for grants,” Nancy Acosta verified.

Suzanne Plemmons explained, “We are able to now determine the frequency of the problems and which are our most common problems. This is where we place our major focus.”

As an example, Suzanne offered the image below.

“This… shows the change in our [KBS] for our maternity support services clients (MSS), for all the problems combined; it’s kind of an average.

“You can see, if you look at the left-hand side, those are the starting average KBS ratings for our clients. Then on the right-hand side you can see the change from admission to discharge of services.

“I think one of the important things for us to realize is that in MSS clients, because of [Nightingale Notes], we know that the average number of visits per client is 3.8 per our last outcomes report.

“So it was pretty amazing to us that we did get a statistically significant improvement in KBS, even though we delivered service for what would be a relatively short period of time for our MSS clients.

Successfully Measuring Outcomes

“This is valuable information to be able to share with our policy makers, our funders, and our executive leadership team here, so that we can continue having our MSS program be a priority program in our community.”

Suzanne went on to explain the benefits of outcome reporting using the image below.

“One of the things that we’re able to do when we do our outcomes report and our data analysis, is we can compare our findings over time.

“You will be able to see that our top three actual problems have pretty much remained constant: income, mental health, and substance use.

“With the exception of our last, most recent report where we have income, mental health, and then pregnancy is the 3rd problem.

“This is valuable information for us as we look at making changes in our practice and the interventions that we use. It really points out, I believe, that we are serving clients who are at risk and need the extra support of [MSS] and also for NFP.”

Benefits of outcome reporting

Suzanne stressed the importance of being able to really look at the outcome data,

“We are able to do that because we have an EHR that is based on the Omaha System and so we do have the outcome rating scale to look at.

But we’re also able to accurately describe our population as far as numbers, ages, ethnicity, educational level, marital status, poverty level, all of those kinds of things.

So we really get a good picture of who we’re serving. And we can accurately describe our services.”

“We actually have an opportunity to look at the results of our outcomes report and make some changes in our practice,” Suzanne said, explaining how Kitsap Public Health District is able to use reports from Omaha System data in Nightingale Notes EHR as a quality improvement tool.

“We are able to see where we have missing data [and] where people are not accurately using the documentation standards we’ve developed.

One of the things we did to make sure our data is as accurate as [possible] is we developed a documentation manual that guides all of the nurses and the social workers that are using the Omaha System in exactly how to [use] it.

So that’s another piece of the inter-rater reliability that Nancy spoke of earlier.”

Nancy added, “Every time we have a report, we see something where we go, ‘that’s not really what we’re doing; something doesn’t seem right.’ So we change it.”

In this way, Kitsap County is able to ensure the data they put into their EHR really shows what they are doing.

Suzanne shared another key element, “[Inter-professional teamwork] is really crucial. We’re fortunate here at Kitsap Public Health District to have a wonderful epidemiology staff… We’re so lucky to have them working with us because they really are our data analysis experts.

“They’re able to extract the data with the Omaha System from our [EHR] and do the data analysis.

“The other piece of it that’s so important, and why they work together as a team, is because the epidemiologist is not an expert in practice.

“So it really needs to be the epidemiologist supplying the data, as well as the nurses and social workers who are out there with the clients.

“[This paints] a fuller picture of why [something’s] happening. They can say, ‘Hmm, that doesn’t seem right, because that’s not what we’re seeing,’ or, ‘Aha! This will guide us to make good change in our practice.’ I think that is a really crucial benefit that we didn’t have before we started using an electronic health record with the Omaha System.”

Both Suzanne and Nancy agree that the journey has been fruitful.

Nancy said, “In our ten years of using our electronic health record, we’ve learned lots of lessons and we’ve been able to share that with lots of local people and at some international conferences.

“We actually talk about the Omaha System to the local nursing class, we have presented at the Omaha System International Conference, the American Public Health Association Conference, the Washington Community Health Leaders Committee Meeting, the Oregon Coalition of Local Health Officials Meeting, and at the NCAST Institute in Seattle.

“We also wrote an article for the American Nursing Informatics (ANIA-CARING) Newsletter. We post outcomes on the Omaha System website.

“We’ve had a number of our co-workers in Washington and Oregon that we’ve met with and we’ve been able to show them how things are going and how they can also utilize their electronic health record.”

Suzanne Plemmons expanded, “I think one thing I’d like to add here is that when we first started out on our journey, we were very fortunate to get help from more experienced users. It was so helpful.

“Judy Riemer from Riverside, California and Karen Monsen, who was then at Washington County in Minnesota, really were good consultants for us and answered many, many questions, and shared things with us that made our process a lot easier than it could have been.

“We were able to get pieces of an RFP from different organization that already had them; that was helpful to us putting together our RFP.

“We were so grateful to all our colleagues for sharing. That puts the onus on us to pay it forward and do the same. We’re always happy to do it.

“We feel like the more people, particularly in our area, who are using the Omaha System in an electronic format, the more comparable data we’ll have and we’ll be able to make a stronger case for continuing on with the benefits of, particularly, our maternal child health practices.”

What to do next

If you want to know more of the Benefits and Features of Nightingale Notes, and how else we can help you, then why not Contact Us at (507) 388-4141 today.

1 The Omaha System. (2016, July 28). Home Page: The Omaha System. Retrieved February 28, 2017, from The Omaha System Web site: | 2 The Omaha System. (2016, March 28). Overview, Problem Rating Scale for Outcomes: The Omaha System. Retrieved February 28, 2017, from The Omaha System website: