Logical Observation Identifiers Names and Codes (LOINC) LOINC
Latest Update via UMLS 2017 Original Publication 1994
The Regenstrief Institute maintains LOINC as a comprehensive clinical terminology for identifying tests, measurements and observations. LOINC includes terms for laboratory test orders and results, clinical measures such as vital signs, standardized survey instruments and other patient observations. Comprised of more than 71,000 observation terms that primarily represent laboratory and clinical observations, it is available at no cost, and it is used extensively within U.S. health IT systems for the exchange of clinical information.
In 1999, it was identified by the Health Level Seven (HL7) Standards Development Organization (SDO) as the preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices and public health authorities (Logical Observation Identifiers Names and Codes (LOINC), 2015). LOINC’s initial purpose was to develop a common terminology for laboratory and clinical observations that could be used in HL7 messages. However, it has been expanded to other areas, including additional clinical observations such as nursing assessment questions. In 2002, the Clinical LOINC Nursing Subcommittee was developed to provide LOINC codes for observations at key stages of the nursing process, including assessments, goals and outcomes, as well as administrative and regulatory data related to nursing care (Nursing Resources for Standards and Interoperability, 2015).
Along with SNOMED CT, LOINC is multidisciplinary. It is available in several file formats for ease of implementation (Regenstrief and the SNOMED International are working together to link LOINC and SNOMED CT., 2013). As part of a cooperative agreement between the Regenstrief Institute and SNOMED International, guidance on the use of SNOMED CT and LOINC together is published with LOINC-SNOMED CT Mappings and Expression Associations to provide a common framework for the use of LOINC with SNOMED CT (Vreeman, 2016).
Process for Updating/Publishing Standard LOINC updates are published every June and December. As a companion to LOINC, the Regenstrief Institute publishes a software tool called Regenstrief LOINC Mapping Assistant (RELMA) to search terminology, assist in the mapping of LOINC to local codes and suggest updates to the LOINC terminology.
Usage/Activity It is estimated that LOINC has more than 44,000 registered account users. LOINC is interoperable with most EHR developer products. When purchased, the user agrees to LOINC’s “Terms of Use” which binds the user and gives notice of LOINC copyright and licensing policy. In the current policy, LOINC permits “in perpetuity, without payment of license fees or royalties, to use, copy or distribute” licensed materials “for any commercial or non-commercial purpose” (Copyright Notice and License). LOINC is a required vocabulary in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Detailed information on each edition’s specific LOINC criterion requirements is in the respective regulations and is referenced in the “Standards Hub” on ONC’s website, here: https:// www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 11
Challenges Because no license is required, it is hard to track specific usage of LOINC. In addition, there is no formal mechanism to monitor the use of LOINC to ensure consistent use and accurate mapping, although the “Terms of Use” state that the “users shall not use any of the Licensed Materials for the purpose of developing or promulgating a different standard for identifying patient observations, such as laboratory test results” (Copyright Notice and License).
Opportunities The study done by Matney to align a minimum set of nursing assessment data with LOINC and SNOMED CT provides a framework for a systematic approach for the standardized representation of nursing assessments (Matney, et al., 2016).
B. Interface Terminologies Interface terminologies are defined as “a systematic collection of health care-related terms that supports clinicians’ entry of patient-related information into computer systems” (Rosenbloom, Miller, Johnson, Brown, & Ekin, 2006). Seven recognized terminologies in this category were designed specifically for use in nursing, but some have evolved to include other disciplines. In addition, ABC Codes are included in this category, although the ANA recognition process originally grouped ABC Codes as a “multidisciplinary” terminology.
1. Clinical Care Classification (CCC) System CCC System
Latest Update via UMLS 2012 Original Publication 1991
A 1991 research project conducted by Dr. Virginia Saba and colleagues from Georgetown University resulted in the development of the Home Health Care Classification System (HHCC), which evolved into the Clinical Care Classification (CCC) System (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). The research focused on creating a process to identify and classify patients to determine resources and measures for outcomes of care. The result was the original version of CCC of Nursing Diagnoses and CCC of Nursing Interventions terminologies that were classified by 20 care components, ultimately establishing a standard framework for assessing, documenting and evaluating nursing care (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). SabaCare Incorporated currently maintains the nursing terminology. The codes are structured within an implicit information model to link nursing diagnoses to interventions and outcomes. There is no license fee for using CCC.
Process for Updating/Publishing Standard The National CCC Advisory Scientific Board, part of SabaCare Incorporated, meets annually to review all submitted concepts, terms or labels for consideration. However, the terminology is not regularly published. Recommendations regarding development of new versions are made only after the Advisory Board has evaluated new ideas. CCC is considering the release of a Plan of Care (PoC) and a Workload Actions Measures Method for new users in the future.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 12
Usage/Activity Dr. Saba states that the CCC System can be used in all clinical settings for documenting nursing practice. Such settings include point-of-care nursing documentation, nursing education, nursing research and nursing administration. The CCC System is being implemented into EHR systems in three different methods (Saba V. , Clinical Care Classification System Version 2.5 User’s Guide, 2012):
Health care facilities obtain CCC System permission to integrate the CCC concepts into the respective facility’s data dictionary. The health care facility uses the CCC System to develop and code its plan of care.
An EHR developer obtains CCC System permission and uses the CCC System to develop a proprietary standardized set of care plans, which is marketed commercially to health care facilities.
An EHR developer obtains CCC System permission and inputs the CCC System’s concepts into its proprietary data dictionaries for use by customers to adapt and develop care plans.
Challenges
Opportunities CCC System is used by a variety of U.S. health systems. There is no licensing fee with CCC, so health systems can use the terminology without incurring that type of expense. The CCC is free for download from: http://www.clinicalcareclassification.com.
2. International Classification for Nursing Practice (ICNP) ICNP
Latest Update via UMLS 2015 Original Publications Alpha version (1996)
Beta version (1999)
None identified.
ICNP is an international terminology that provides description and comparison for nursing practice and allows for cross-mapping between other terminologies. The classification includes nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions. Specifically, ICNP describes nursing care of people in a variety of settings and enables comparison of nursing data across clinical populations, settings and geographical areas and time ((ICN), n.d.). The International Council of Nurses (ICN) developed ICNP in 1990 (formalized in 2000) to be a unifying framework in which local language and existing nursing terminologies and classifications could be cross-mapped to support data interoperability. ICN owns and copyrights ICNP; permission for use is required. Commercial use involving distribution of a product for-profit (e.g. software products or publications) requires a small licensing fee; non-commercial use (e.g. research in education) is free (Coenen A. , 2003). Other uses, such as government use within a national health information system, are negotiated on a case-by-case basis. ICN anticipates discounted pricing for developing countries. Besides protection of copyright, ICN is most concerned about facilitating access to ICNP for use by nurses (Coenen A. , 2003).
Identifying Challenges and Opportunities within Standard Nursing Terminologies 13
Process for Updating/Publishing Standard The alpha version released in 1996; the Beta version followed in 2000. The last updated publication is June 2015. ICNP, along with translations and other derived products, is disseminated every two years to maintain currency and keep pace with nursing practice advances. Maintaining terminology is a major task that includes tracking recommendations and suggestions, expert reviews and revisions to the ICNP as well as organizing committee meetings, conference presentations and ad hoc groups (Coenen A. , 2003).
Usage/Activity ICNP is an international nursing standard; nursing associations can become members to access terminology for further dissemination. The terminology was established as an international standard for description and comparison of the nursing practice (2015AB UMLS ICNP Source Information, 2016). The ICNP translations are produced with the cooperation of the National Nursing Association. Translations are available in Arabic, German, Italian, Japanese, Korean, Norwegian, Polish, Portuguese and Spanish with additional translations in Farsi (Persian), French, Greek and Mandarin. Thai and Turkish versions are being developed.
In September 2015, ICN and SNOMED International announced the delivery of a diagnoses equivalency table between ICNP and SNOMED CT, with a focus on nursing diagnoses, to provide transformation of ICNP-encoded data to SNOMED CT (International Council of Nurses (ICN) and IHTSDO deliver collaborative product., 2015). The collaboration ensures that users can continue to use ICNP while participating in the wider implementation of SNOMED CT globally. In April 2016, an equivalency table of ICNP to SNOMED CT nursing interventions was released. Any usage of the equivalency tables must comply with the licensing agreement of both ICNP and SNOMED CT (International Council of Nurses (ICN) and IHTSDO deliver collaborative product., 2015). The ICN has collaborated with SabaCare to develop linkages between the CCC and ICNP concepts including publication of the 2014 CCC-ICNP Equivalency Table for Nursing Diagnoses (Hardiker & Saba, 2016).
Challenges SMEs interviewed said ICNP was not used within the United States. Many countries using ICNP are implementing it on a national level.
Opportunities nursing
interventions equivalency table (August 2015) and a nursing diagnoses equivalency table (April 2015) have been released, which will help support international users
ICN is working in conjunction with SNOMED International to deliver equivalency tables; a
Identifying Challenges and Opportunities within Standard Nursing Terminologies 14
Logical Observation Identifiers Names and Codes (LOINC) LOINC
Latest Update via UMLS 2017 Original Publication 1994
The Regenstrief Institute maintains LOINC as a comprehensive clinical terminology for identifying tests, measurements and observations. LOINC includes terms for laboratory test orders and results, clinical measures such as vital signs, standardized survey instruments and other patient observations. Comprised of more than 71,000 observation terms that primarily represent laboratory and clinical observations, it is available at no cost, and it is used extensively within U.S. health IT systems for the exchange of clinical information.
In 1999, it was identified by the Health Level Seven (HL7) Standards Development Organization (SDO) as the preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices and public health authorities (Logical Observation Identifiers Names and Codes (LOINC), 2015). LOINC’s initial purpose was to develop a common terminology for laboratory and clinical observations that could be used in HL7 messages. However, it has been expanded to other areas, including additional clinical observations such as nursing assessment questions. In 2002, the Clinical LOINC Nursing Subcommittee was developed to provide LOINC codes for observations at key stages of the nursing process, including assessments, goals and outcomes, as well as administrative and regulatory data related to nursing care (Nursing Resources for Standards and Interoperability, 2015).
Along with SNOMED CT, LOINC is multidisciplinary. It is available in several file formats for ease of implementation (Regenstrief and the SNOMED International are working together to link LOINC and SNOMED CT., 2013). As part of a cooperative agreement between the Regenstrief Institute and SNOMED International, guidance on the use of SNOMED CT and LOINC together is published with LOINC-SNOMED CT Mappings and Expression Associations to provide a common framework for the use of LOINC with SNOMED CT (Vreeman, 2016).
Process for Updating/Publishing Standard LOINC updates are published every June and December. As a companion to LOINC, the Regenstrief Institute publishes a software tool called Regenstrief LOINC Mapping Assistant (RELMA) to search terminology, assist in the mapping of LOINC to local codes and suggest updates to the LOINC terminology.
Usage/Activity It is estimated that LOINC has more than 44,000 registered account users. LOINC is interoperable with most EHR developer products. When purchased, the user agrees to LOINC’s “Terms of Use” which binds the user and gives notice of LOINC copyright and licensing policy. In the current policy, LOINC permits “in perpetuity, without payment of license fees or royalties, to use, copy or distribute” licensed materials “for any commercial or non-commercial purpose” (Copyright Notice and License). LOINC is a required vocabulary in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Detailed information on each edition’s specific LOINC criterion requirements is in the respective regulations and is referenced in the “Standards Hub” on ONC’s website, here: https:// www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 11
Challenges Because no license is required, it is hard to track specific usage of LOINC. In addition, there is no formal mechanism to monitor the use of LOINC to ensure consistent use and accurate mapping, although the “Terms of Use” state that the “users shall not use any of the Licensed Materials for the purpose of developing or promulgating a different standard for identifying patient observations, such as laboratory test results” (Copyright Notice and License).
Opportunities The study done by Matney to align a minimum set of nursing assessment data with LOINC and SNOMED CT provides a framework for a systematic approach for the standardized representation of nursing assessments (Matney, et al., 2016).
B. Interface Terminologies Interface terminologies are defined as “a systematic collection of health care-related terms that supports clinicians’ entry of patient-related information into computer systems” (Rosenbloom, Miller, Johnson, Brown, & Ekin, 2006). Seven recognized terminologies in this category were designed specifically for use in nursing, but some have evolved to include other disciplines. In addition, ABC Codes are included in this category, although the ANA recognition process originally grouped ABC Codes as a “multidisciplinary” terminology.
1. Clinical Care Classification (CCC) System CCC System
Latest Update via UMLS 2012 Original Publication 1991
A 1991 research project conducted by Dr. Virginia Saba and colleagues from Georgetown University resulted in the development of the Home Health Care Classification System (HHCC), which evolved into the Clinical Care Classification (CCC) System (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). The research focused on creating a process to identify and classify patients to determine resources and measures for outcomes of care. The result was the original version of CCC of Nursing Diagnoses and CCC of Nursing Interventions terminologies that were classified by 20 care components, ultimately establishing a standard framework for assessing, documenting and evaluating nursing care (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). SabaCare Incorporated currently maintains the nursing terminology. The codes are structured within an implicit information model to link nursing diagnoses to interventions and outcomes. There is no license fee for using CCC.
Process for Updating/Publishing Standard The National CCC Advisory Scientific Board, part of SabaCare Incorporated, meets annually to review all submitted concepts, terms or labels for consideration. However, the terminology is not regularly published. Recommendations regarding development of new versions are made only after the Advisory Board has evaluated new ideas. CCC is considering the release of a Plan of Care (PoC) and a Workload Actions Measures Method for new users in the future.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 12
Usage/Activity Dr. Saba states that the CCC System can be used in all clinical settings for documenting nursing practice. Such settings include point-of-care nursing documentation, nursing education, nursing research and nursing administration. The CCC System is being implemented into EHR systems in three different methods (Saba V. , Clinical Care Classification System Version 2.5 User’s Guide, 2012):
Health care facilities obtain CCC System permission to integrate the CCC concepts into the respective facility’s data dictionary. The health care facility uses the CCC System to develop and code its plan of care.
An EHR developer obtains CCC System permission and uses the CCC System to develop a proprietary standardized set of care plans, which is marketed commercially to health care facilities.
An EHR developer obtains CCC System permission and inputs the CCC System’s concepts into its proprietary data dictionaries for use by customers to adapt and develop care plans.
Challenges
Opportunities CCC System is used by a variety of U.S. health systems. There is no licensing fee with CCC, so health systems can use the terminology without incurring that type of expense. The CCC is free for download from: http://www.clinicalcareclassification.com.
2. International Classification for Nursing Practice (ICNP) ICNP
Latest Update via UMLS 2015 Original Publications Alpha version (1996)
Beta version (1999)
None identified.
ICNP is an international terminology that provides description and comparison for nursing practice and allows for cross-mapping between other terminologies. The classification includes nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions. Specifically, ICNP describes nursing care of people in a variety of settings and enables comparison of nursing data across clinical populations, settings and geographical areas and time ((ICN), n.d.). The International Council of Nurses (ICN) developed ICNP in 1990 (formalized in 2000) to be a unifying framework in which local language and existing nursing terminologies and classifications could be cross-mapped to support data interoperability. ICN owns and copyrights ICNP; permission for use is required. Commercial use involving distribution of a product for-profit (e.g. software products or publications) requires a small licensing fee; non-commercial use (e.g. research in education) is free (Coenen A. , 2003). Other uses, such as government use within a national health information system, are negotiated on a case-by-case basis. ICN anticipates discounted pricing for developing countries. Besides protection of copyright, ICN is most concerned about facilitating access to ICNP for use by nurses (Coenen A. , 2003).
Identifying Challenges and Opportunities within Standard Nursing Terminologies 13
Process for Updating/Publishing Standard The alpha version released in 1996; the Beta version followed in 2000. The last updated publication is June 2015. ICNP, along with translations and other derived products, is disseminated every two years to maintain currency and keep pace with nursing practice advances. Maintaining terminology is a major task that includes tracking recommendations and suggestions, expert reviews and revisions to the ICNP as well as organizing committee meetings, conference presentations and ad hoc groups (Coenen A. , 2003).
Usage/Activity ICNP is an international nursing standard; nursing associations can become members to access terminology for further dissemination. The terminology was established as an international standard for description and comparison of the nursing practice (2015AB UMLS ICNP Source Information, 2016). The ICNP translations are produced with the cooperation of the National Nursing Association. Translations are available in Arabic, German, Italian, Japanese, Korean, Norwegian, Polish, Portuguese and Spanish with additional translations in Farsi (Persian), French, Greek and Mandarin. Thai and Turkish versions are being developed.
In September 2015, ICN and SNOMED International announced the delivery of a diagnoses equivalency table between ICNP and SNOMED CT, with a focus on nursing diagnoses, to provide transformation of ICNP-encoded data to SNOMED CT (International Council of Nurses (ICN) and IHTSDO deliver collaborative product., 2015). The collaboration ensures that users can continue to use ICNP while participating in the wider implementation of SNOMED CT globally. In April 2016, an equivalency table of ICNP to SNOMED CT nursing interventions was released. Any usage of the equivalency tables must comply with the licensing agreement of both ICNP and SNOMED CT (International Council of Nurses (ICN) and IHTSDO deliver collaborative product., 2015). The ICN has collaborated with SabaCare to develop linkages between the CCC and ICNP concepts including publication of the 2014 CCC-ICNP Equivalency Table for Nursing Diagnoses (Hardiker & Saba, 2016).
Challenges SMEs interviewed said ICNP was not used within the United States. Many countries using ICNP are implementing it on a national level.
Opportunities nursing
interventions equivalency table (August 2015) and a nursing diagnoses equivalency table (April 2015) have been released, which will help support international users
ICN is working in conjunction with SNOMED International to deliver equivalency tables; a