Incomplete Electronic Documentation of Nursing Care
Identifying Challenges and Opportunities within Standard Nursing Terminologies 26
VIII. Conclusion
In addressing the need to capture nursing data, Welton and Harper (2016) stated, “…as we move toward a value- oriented health care system, there is a growing need to address the largest human capital component of the system, nursing care, and devise methods and actions to understand better how nursing costs and resources are expended for each patient and how these relate to the quality and outcomes of care” (Welton & Harper, Measuring Nursing Care Value, 2016). Without commitment from nursing on a comprehensive strategy for data standardization, the vision of representing nursing care in the data will never be realized fully. More importantly, the interdisciplinary care team interacting with the patient may not be privy to nursing data across the care continuum and ultimately, patient outcomes may be negatively impacted.
In order to realize the full potential of health IT, the ability to achieve interoperability using consistent standards and common data elements is paramount. The increasing amount of data available to perform sophisticated analytics and support clinicians in their delivery of good-quality patient care presents a tremendous opportunity to improve the health of patients and represent the work performed by registered nurses across care settings.
The purpose of this report was not to solve the problem of how to best capture nursing data; we recognize there are many talented individuals who are working to achieve this goal of data capture. Rather, we hope to provide readers with a baseline analysis of the current state of standard nursing terminologies, including their challenges and opportunities, and perhaps foster further discussion in this knowledge domain. Despite decades of work in this field, perspectives have failed to align while the landscape of patient care has changed dramatically with the advent of alternative payment models, payment for quality and outcomes, a focus on population health, and increasing requirements for interdisciplinary care planning and documentation. The ability to move forward with a comprehensive nursing terminology strategy could play a key role in the increased visibility of registered nurses in this new world of changing care models. More important, that visibility and measurement of “what nurses do” both individually and as a member of the care team could significantly improve outcomes for patients.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 27
Appendix A: Expanded Nursing Terminologies Timeline
1973. The First National Congress on the Classification of Nursing Diagnoses takes place in St. Louis.
1982. The North American Nursing Diagnosis Association (NANDA) is founded.
1989. James J. Cimino et al authors “Designing an Introspective, Multipurpose, Controlled Medical Vocabulary” which describes seven features that a controlled health care vocabulary should possess. See Exhibit A below for additional information.
Exhibit A: Seven Properties of a Controlled Vocabulary 1. Domain Completeness: The ability to accommodate appropriately all necessary concepts.
Schemes should not limit depth or breadth of hierarchies. Compositional approaches allow complex concepts to be represented.
2. Unambiguous: Terms should clearly represent only a single concept (see semiotic triangle). Synonyms should be pure.
3. Non-redundancy: There must be only one way of representing a concept in the vocabulary, or equivalences between alternative representations should be detectable.
4. Synonymy: More than one term (synonym) may describe the same concept. 5. Multiple Classification: Entities from the vocabulary should be placed in more than one
hierarchy location if appropriate. For example, Carcinoma of the colon is both a Malignant disease and a Large intestinal disease.
6. Consistency of Views: Cimino identified the problem of multiple classification being inconsistent or incomplete and that qualifiers or modifiers might vary between different parts of the hierarchy.
7. Explicit Relationship: The nature of relationships between concepts in the vocabulary structure should be explicit and usually sub-class.
1989. The ANA establishes the Steering Committee on Databases to Support Nursing Practices to develop criteria for recognition of nursing terminologies.
1990. The ANA House of Delegates passes a resolution recommending that the Nursing Minimum Data Set (NMDS) be used as the essential data elements to define the cost and quality of nursing practice.
1994. The ANA Steering Committee on Databases to Support Clinical Nursing Practice recognizes four nursing classification schemes for use in national databases in the United States.
1997. The ANA publishes a book titled “Nursing Information & Data Set Evaluation Center (NIDSEC): Standards and Scoring Guidelines.” In this book, the ANA publicizes the early stages of guidelines to use to evaluate information systems that support the documentation of nursing practice. The information systems are evaluated based on four dimensions: 1) Nomenclature – terms must be contained in the UMLS and reflect the current recognized SNTs; 2) Clinical Content – representing the nursing process; 3) Data Repository – existence of a clinical data repository (CDR) to store data longitudinally; and 4) General System Characteristics– characteristics of the hardware/software system to support storage of nursing data and the processing requirements of the CDR.
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1997. Beginning in 1997, the American Medical Informatics Association (AMIA) Nursing Informatics Working Group (NIWG) sponsors activities to support the facilitation of information between nursing terminology experts and other informatics stakeholders. This includes tutorials, workshops and panels as well as publication of articles.
1998. James J. Cimino publishes an extension of his 1989 work, titled “Desiderata for Controlled Medical Vocabularies in the Twenty-First Century.” In this work, Cimino expands upon his earlier work and describes 12 common themes that every terminology needs to achieve to be considered standardized. Cimino emphasized the “sharability of vocabulary” which refers to the ability of the vocabulary “to be used to record data for one purpose and then be used for reasoning about the data usually through a variety of views or abstractions of the specific codes used in data capture.” See Exhibit B for additional information.
Exhibit B: Cimino’s Twelve Desiderata Points
1. Content: To most users “What can be said” is more important than “how it can be said.” Omissions are readily noticed and timely, formal and explicit methods for plugging gaps are required.
2. Concept Orientation: The unit of symbolic processing is the concept, and each concept in the vocabulary should have a single, coherent meaning.
3. Concept Permanence: A concept’s meaning cannot change, and it cannot be deleted from the vocabulary.
4. Meaningless Concept Identifiers: Concepts typically have unique identifiers (codes), and these should be non-hierarchical to allow for later relocation and multiple classifications.
5. Polyhierarchy: Entities from the vocabulary should be placed in more than one hierarchy location if appropriate.
6. Formal Definitions: Semantic definitions of concepts, for example, Streptococcal tonsillitis = Infection of tonsil caused by streptococcus.
7. No residual categories: Traditional classifications have rubrics that include not otherwise specified (NOS), not elsewhere classified (NEC), unspecified or other. These are not appropriate for recording data in an electronic health record.
8. Multiple Granularities: Different users require different levels of expressivity. A general (family) practitioner might use myocardial infarction while a surgeon may record acute anteroseptal myocardial infarction.
9. Multiple Consistent Views: Although there may be multiple views of the hierarchy required to support different functional requirements and levels of detail, these must be consistent.
10. Content Representation: There is a crucial relationship between concepts within the vocabulary and the context in which they are used. Cimino defines three types of knowledge: Definitional (how concepts define one another), Assertional (how concepts combine) and Contextual (how concepts are used).
11. Graceful Evolution: Vocabularies must be designed to allow for growth and change to incorporate new advances in health care and to correct errors.
12. Recognized Redundancy: Where the same information can be expressed in different ways, a mechanism for verifying equivalence is required.
1999. The ANA upates its criteria for recognition of nursing terminologies using the International Standards Organization (ISO) standards for terminologies.
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June 1999. Vanderbilt University convenes the Nursing Vocabulary Summit Conference with the objective of reaching consensus on characteristics of a nursing terminology standard. One of the primary outcomes of this summit is a realization that no one classification system can serve as the standard, but rather efforts need to be made to develop a reference terminology to harmonize existing standards. Held annually until 2008, the work of the conference contributes to the adoption of standards for nursing.
July 2000. The National Committee on Vital and Health Statistics (NCVHS) publishes a report titled “Uniform Data Standards for Patient Medical Record Information” to the U.S. Department of Health and Human Services (HHS) regarding the adoption of uniform data standards for patient medical record information (PMRI) and the electronic exchange of such information. The report establishes four guiding principles for PMRI terminology:
Terminology should enable interoperability between information systems; Terminology should facilitate the comparability of data; Terminology should have aspects that support data quality, accountability and integrity; and Terminology should have a degree of market acceptance.
December 2002. NCVHS publishes a subsequent report that focuses on the appropriate scope and criteria of a uniform data standard. Within this report, NCVHS recognizes essential and desired technical and organizational criteria that mirror Cimino’s “Desiderata.” Some essential technical criteria include ideas around concept orientation (each concept having a single coherent meaning) and permanence (a concept meaning should not be changed). Some organizational criteria include the establishment of a governance structure and development of a funding mechanism.