Application Exercise-Nursing Terminology|Legit essays

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Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care

By

Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions;

Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas;

Jane Brokel, PhD, RN, NANDA International;

Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification;

Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification;

Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification;

Marion Johnson, PhD, RN; Nursing Outcomes Classification;

Meridean Maas PhD, RN; Nursing Outcomes Classification;

Karen S. Martin, RN, NSN, FAAN; Omaha System;

Sue Moorhead PhD, RN, Nursing Outcomes Classification;

Christine Spisla, RN, MSN; SNOMED Terminology Solutions;

Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification,

Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses

Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf

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Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs.

Key Words: Nursing Terminology, Standardized nursing terminology, NANDA International, Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT)

Introduction The care nurses provide to

sustain life, enable recovery, alleviate suffering and promote health should be captured within the electronic health record (EHR). To share this information between clinical disciplines and care settings, data needs to be recorded and stored in a standardized form. Terminologies are one way to ensure standardization so patient care data can be stored in an unambiguous way. Nursing has numerous terminologies, each developed for a

variety of care settings. Selecting the appropriate nursing terminology implementation for use in the EHR can be daunting.

This article will highlight selected American Nursing Association’s (ANA) recognized nursing terminologies and their relationships to each other. This discussion will assist in making decisions about the combination of nursing terminologies that best fit your organization’s practice and requirements for the EHR.

Benefits of Implementing Standardized Terminologies within Electronic Health Records

Standardized nursing terminologies provide benefits to the patient, the organization, the nursing profession, and each country. Patients benefit from continuity of care being facilitated through the use of standardized terminologies through improved and unambiguous communication between clinicians. Organizations

benefit by being able to measure nursing care and its impact on patient care through queries of the patient record instead of costly manual chart audits. This determination of nursing’s impact is essential to validating the contribution of nursing to healthcare and patient safety. Furthermore, the organization

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benefits from the use of standard terminologies by providing administrators with the actual costs and benefits of nursing care. Then informed decisions can be made regarding staffing ratios. This strategy has been useful for physicians using the Common Procedural Terminology (CPT codes) for billing purposes (Giannangelo & Fenton, 2008). Nurse educators use standardized terminologies in the curriculum to teach nursing concepts that are critical in the nursing process and are vital to developing new nurses (Warren, Connors, & Weaver, 2002). The registered nurse benefits from the use of standardized nursing terminologies to facilitate critical thinking and decision making at the point of care (Dochterman, Titler, Wang, & Reed, 2005). The nursing profession benefits from being provided a means to document, store, and retrieve evidence-based practice in a semantic way to facilitate nursing research and

reveal the impact of nursing care through electronic means (Weaver, Warren, & Delaney, 2005). Each country benefits by having retrievable coded data that can be aggregated into informative reports or data sets. These reports allow countries to compare nursing’s contribution to care both nationally and internationally using the International Nursing Minimum Data Set. (Goosen, et al, 2006).

The standardized nursing terminologies, recognized by the American Nursing Association (ANA), are the vehicles for the aggregation of nursing data recorded in EHRs which can be used to improve quality of patient care and patient safety. Giannangelo and Fenton (2008) state that EHRs “must use consistent, codified terminology to eliminate ambiguity, confusion, and ensure data correctness and interoperability…standardized terminologies identify the discrete structured data that allow data capture and processing (p. 29).”

American Nursing Association Recognized Terminologies

The ANA Committee for Nursing Practice Information Infrastructure (CNPII) has defined specific criteria used to recognize standardized terminologies. These criteria are foundational to the standardization of nursing documentation and verbal communication that will lead to a reduction in errors and an increase in the quality and continuity of care (American Nursing Association [ANA], 2006, 1). The ANA criteria require that terminologies possess

vocabulary that supports nursing and are clinically relevant for the nursing domain. The terminologies need to possess clear and unambiguous concepts with a coding scheme containing one unique identifier per concept. The terminologies must contain documented testing of reliability, validity and clinical usefulness in practice to become recognized (American Nursing Association [ANA], 2006, 1). The ANA recognized nursing terminologies

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are listed in alphabetical order in Table 1.

Table 1: ANA recognized terminologies ANA Recognized

Terminologies Terminology URL Nursing Process

within Terminology Date

Recognized by the ANA

Integrated Within Other Terminologies

CCC Clinical Care Classification

http://www.sabacare.com/ Diagnoses, Interventions, and Outcomes

ICNP International Classification of Nursing Practice

http://www.icn.ch/icnp.ht m

Diagnoses, Interventions, and Outcomes

NANDA NANDA International

www.nanda.org Nursing Diagnoses 1992 NLM- UMLS SNOMED CT PNDS HL7 NIDSEC

NIC Nursing Intervention Classification

www.nursing.uiowa.edu/c nc

Interventions 1992 NLM- UMLS SNOMED CT HL7 NIDSEC ABC Codes

NOC Nursing Outcome Classification

www.nursing.uiowa.edu/c nc

Outcomes Indicators

1998 NLM- UMLS SNOMED CT HL7 NIDSEC

Omaha System

www.omahasystem.org Problem Classification Scheme Intervention Scheme Problem Rating Scale for Outcomes

1992 NLM- UMLS SNOMED CT HL7 NIDSEC LOINC ABC Codes

PNDS Perioperative Nursing Data Set

www.aorn.org/PracticeRe sources/PNDS

Diagnoses, Interventions and Outcomes

1999 NLM- UMLS SNOMED CT HL7

SNOMED CT Systematic Nomenclature of Medicine Clinical Terms

httpwww.cap.org/apps/ca p.portal? _nfpb=true&_pageLabel= snomed_page

Assessment concepts, Diagnoses, Interventions, and Outcomes

2002 NLM- UMLS

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Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)

SNOMED CT is a comprehensive, scientifically validated clinical terminology and infrastructure for healthcare containing a broad coverage of terminology supporting healthcare documentation through the continuum of care. SNOMED CT provides a consistent way of indexing, storing, retrieving and aggregating clinical data across specialties and sites of care. The use of SNOMED CT within electronic health records provides interoperable data extraction and analysis that can be shared across clinicians, clinical settings and organizations both nationally and internationally.

SNOMED CT is in conformance with National industry regulatory standards and the Consolidated Health Initiative (CHI) [ONC, 2006]. The National Committee on Vital and Health Statistics (NCVHS) in 2003 rated SNOMED CT highest among all terminologies evaluated for electronic health record as it met the essential criteria defined according to sound medical informatics practices (SNOMED Terminology Solutions, SNOMED CT 2007). SNOMED CT is in compliance with allied standards by enabling SNOMED CT to effectively interoperate with other standards such as the International Standards Organization (ISO), Health Language 7 (HL7) and National Quality Forum (NQF).

SNOMED CT is a clinical terminology comprised of codes,

concepts and relationships used precisely in recording and representing clinical information across the scope of healthcare. SNOMED CT is concept-based, meaning each concept has a distinct definition and a unique code identifier. SNOMED CT consists of 19 top-level hierarchies, e.g.: procedures (medical and surgical procedures, laboratory and radiology procedures, interventions, education and management procedures), clinical findings, (nursing diagnoses, disorders, diseases that are necessarily abnormal, clinical observations and signs and symptoms) body structures, observable entity (concepts that represent questions being asked during an assessment), devices, substances, and medications.

SNOMED CT hierarchies are created through defining relationships linking one concept to another concept for the purpose of defining each concept down to its specific meaning. Defining concepts by using parent-child relationship begins to build vertical hierarchies within SNOMED CT. Concepts lower in the hierarchy are more specific in meaning then concepts higher up in the hierarchy, creating multiple levels of granularity. Defining relationship attributes further defines the concept’s meaning by relating all that is necessary and sufficient to fully represent the concept’s definition.

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Table 2: SNOMED CT Example SNOMED CT Definition of chest pain Pain (finding) IsA Chest pain (finding) Finding Site: Thoracic structure (body structure) IsA Pain of truncal structure (finding) IsA Pain finding at anatomical site (finding) IsA Clinical finding (finding)

The way concepts are defined in SNOMED CT makes up its logical concept definition that is necessary to extract a robust data aggregation used to support research and analysis.

Integration of the ANA recognized standardized terminologies within SNOMED Reference Terminology (SNOMED RT) began by collaborating with each of the nursing terminology developers to ensure accurate terminology representation. The SNOMED Nursing Working Group identified additional defining relationships needed to define concepts within the nursing domain. These defining relationships are consistent with the International Standard Organization (ISO) Nursing Terminology Model Standard for diagnoses and interventions.

Once the ANA recognized terminologies were integrated within SNOMED RT, and before they were released within

SNOMED CT core, the terminology developers validated the mappings to ensure accurate representation of the nursing concepts and that the concepts were defined equivalently as represented within their terminology system.

The ANA recognized nursing terminologies provide nurse-sensitive terminology needed to encode the nursing domain. SNOMED CT can be used to encode nursing documentation of the full healthcare encounter e.g.: acute care, home care, hospice care, spiritual health, long-term care and health care clinic visits. SNOMED CT can be used to encode assessments, flow-sheets, education plans, care plans, task lists and nursing notes within the electronic health record. The ANA recognized terminologies that have been integrated within SNOMED CT are presented in alphabetical order in table 3.

Table 3: ANA Recognized Terminologies integrated within SNOMED CT ANA Recognized Terminologies

Data elements integrated within SNOMED CT

Concepts in SNOMED Hierarchies

Clinical Care Classification (CCC)

Diagnoses, Interventions Diagnoses – Clinical findings Interventions – Procedures

SOLUTION

specific purpose, to capture the knowledge, interventions, outcomes and diagnoses related to patient care. Using standardized nursing terminologies in the EHR has several benefits, including improved patient outcomes, increased patient safety, better communication among healthcare professionals, and increased cost-effectiveness.

The various nursing terminologies include NANDA International (NANDA-I), Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT).

NANDA-I provides a standardized language for describing nursing diagnoses, which are defined as the individual or family responses to actual or potential health problems or life processes. NIC provides a standardized language for describing nursing interventions, which are defined as the treatments or actions taken by the nurse to achieve a desired patient outcome. NOC provides a standardized language for describing nursing outcomes, which are defined as the results or changes in patient status that result from nursing interventions.