Standard Nursing Terminologies: A Landscape Analysis
MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726
May 15, 2017
Identifying Challenges and Opportunities within Standard Nursing Terminologies 2
Table of Contents
I. Introduction …………………………………………………………………………………………. 4
II. Background ………………………………………………………………………………………….. 4
III. Landscape Analysis Approach ………………………………………………………………….. 6
IV. Summary of Background Data …………………………………………………………………. 7
V. Findings……………………………………………………………………………………………….. 8 A. Reference Terminologies ………………………………………………………………………………………..8
1. SNOMED CT ………………………………………………………………………………………………………………….. 8
2. Logical Observation Identifiers Names and Codes (LOINC) ……………………………………………….. 10
B. Interface Terminologies ………………………………………………………………………………………. 11
1. Clinical Care Classification (CCC) System ………………………………………………………………………… 11
2. International Classification for Nursing Practice (ICNP) ……………………………………………………. 12
3. NANDA International (NANDA-I) ……………………………………………………………………………………. 14
4.
5. Omaha System ……………………………………………………………………………………………………………. 16
6. Perioperative Nursing Data Set (PNDS) ………………………………………………………………………….. 18
7. Alternative Billing Concepts (ABC) Codes ……………………………………………………………………….. 19
C. Minimum Data Sets ……………………………………………………………………………………………. 20
1. Nursing Minimum Data Set (NMDS) ………………………………………………………………………………. 20
2. Nursing Management Minimum Data Set (NMMDS) ……………………………………………………….. 22
VI. Health IT Developers – Perspective …………………………………………………………. 23
VII. Emerging Issues in Using SNTs ……………………………………………………………….. 24 1. Lack of Alignment on Terminology Standards for Nursing Content Definition …………………….. 24
2. Customized Development and Implementation of EHR Systems ……………………………………….. 24
3. Resource-Intensive Mapping Requirements, Curation and Maintenance …………………………… 24
4. Licensing Fees, Copyrights and Associated Pricing Challenges …………………………………………… 25
5. Incomplete Electronic Documentation of Nursing Care ……………………………………………………. 25
4. Nursing Interventions Classification System (NIC) and Nursing Outcomes Classification (NOC) …………………………………………………………………………………………………….. 15
Identifying Challenges and Opportunities within Standard Nursing Terminologies 3
VIII. Conclusion …………………………………………………………………………………………. 26
Appendix A: Expanded Nursing Terminologies Timeline ……………………………………… 27
Appendix B: Pre-Determined Landscape Assessment Questionnaire …………………….. 34
Appendix C: EHR Developer Assessment Questionnaire ……………………………………… 35
Appendix D: List of Abbreviations …………………………………………………………………… 36
References ………………………………………………………………………………………………….. 38
Identifying Challenges and Opportunities within Standard Nursing Terminologies 4
I. Introduction
With the rapid adoption of health IT and the promotion of interoperability to improve health, consistent standards and common data elements are the foundation for the advancement of care models. This advancement is based on objectives such as capturing sharable patient and care information across disciplines and care settings, enabling more accurate and less burdensome measurement of the quality of care delivered, and supporting ongoing research and analysis. Within this context, the nursing profession can contribute an enormous amount of valuable data related to the care of the patient and the nursing process. However, if nursing data are not stored in a standardized electronic format, or easily translated to a vocabulary used by interdisciplinary care team members, the value and contributions of nursing to patient outcomes may not be measurable or retrievable (Welton & Harper, Measuring Nursing Care Value, 2016). With more than 3.6 million members, nurses constitute the largest workforce in health care, and hospital-based nurses spend as much as 50 percent of their time in direct patient care (Hurst) (Nursing Fact Sheet, 2011) (McMenamin, 2016). As we move forward with innovative strategies to optimize the health of patients and communities, the omission of nursing data due to a lack of agreement on a standardization strategy would be unfortunate.
To this end, the Office of the National Coordinator for Health IT (ONC) is working with MBL Technologies and Clinovations Government + Health, Inc. (Clinovations GovHealth) (hereafter the project team) to conduct a landscape assessment to better understand the current state and challenges associated with using terminologies and classifications to support nursing practice within health information technology (health IT) solutions. Through a literature review and interviews with terminology owners, this assessment examines the current state of development and usage within the 12 Standard Nursing Terminologies (SNT) recognized by the American Nurses Association (ANA).
This report:
Defines a brief history of the development of standard nursing terminologies and efforts to gain consensus on a strategy for their use;
Includes the level of advancement and interoperability of individual terminologies with electronic health records (EHRs); and