Identifying Challenges and Opportunities within Standard Nursing Terminologies 6
communicate similar meaning across systems (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008).
Table 1 below includes the 12 SNTs by category.
Table 1. ANA-Recognized Standard Nursing Terminologies
Interface Terminologies Minimum Data Sets 1. Clinical Care Classification (CCC) System 2. International Classification for Nursing
Practice (ICNP) 3. North American Nursing Diagnosis
Association International (NANDA-I) 4. Nursing Interventions Classification System
(NIC) 5. Nursing Outcomes Classification (NOC) 6. Omaha System 7. Perioperative Nursing Data Set (PNDS) 8. ABC Codes
1. Nursing Minimum Data Set (NMDS) 2. Nursing Management Minimum Data
Set (NMMDS)
Reference Terminologies 1. Logical Observation Identifiers Names
and Codes (LOINC) 2. SNOMED Clinical Terms (SNOMED CT)
III. Landscape Analysis Approach
The project team first performed an internet search to obtain background on standard nursing terminologies. Using information gathered in the search and focusing specifically on ANA-recognized SNTs, the project team proposed a list of interview contacts within each ONC-validated SNT organization. Interviews were conducted using an interview guide (Appendix B). For accuracy purposes, the project team used standardized definitions for the variables of current usage, existing interoperability and major barriers or issues to implementing and using SNT. Data on the following topics was collected for analysis:
SNT goals and objectives for the terminology ; Terminology versioning and release schedules; Latest version of SNT as well as update timing and methodology; Current usage and activities; Maintenance and sustainability issues; Level of interoperability with electronic health records; Major issues or barriers associated with integration and implementation; and The future state of the SNT.
Discussions touched on each SNT’s perceived or actual barriers to interoperability, how easily an SNT is implemented within an EHR, and the typical process for that implementation. Details of those interviews are in Section IV: Summary of Background Data, below.
After completion of interviews with terminology representatives, the project team approached three electronic health record developers to provided background on how SNTs are implemented and used in hospital and ambulatory health information technology applications. Although these interviews were
Identifying Challenges and Opportunities within Standard Nursing Terminologies 7
unstructured, the project team developed a framework for guiding the discussion (Appendix C). Developer interviews were collated and overarching perspectives were identified for further discussion in Section VI: Health IT Developers – Perspectives. When all data collection was complete, the project team evaluated the information to identify gaps, similarities, barriers, challenges and opportunities related to the current status and use of SNTs. This information is in Section VII: Emerging Issues in Using SNTs.
IV. Summary of Background Data
The table below summarizes the background data collected during the landscape analysis.
Table 2. Summary of Background Data
Terminology Latest Update via
UMLS Original
Publication Date Publication Schedule SNOMED Clinical Terms (SNOMED CT)
2017 SNOMED (1975) SNOMED II (1979) SNOMED CT (2002)
Twice annually: January and July.
Logical Observation Identifiers Names and Codes (LOINC)
2017 1994 Twice annually: December and June.
Alternative Billing Concepts (ABC) Codes
2009 2000 Schedule based on availability of resources.
Clinical Care Classification (CCC) System
2012 1991 CCC System National Scientific Advisory Board meets annually.
International Classification for Nursing Practice (ICNP)
2015 Alpha v. (1996) Released in May or June of the second year.
NANDA International (NANDA-I)
2002 1973 Every three years.
Nursing Interventions Classification System (NIC)
2008 1992 Every five years.
Nursing Outcomes Classification (NOC)
2008 1997 Every five years.
Omaha System 2005 1975 Reviewed every two years. Perioperative Nursing Data Set (PNDS)
2011 1999 Every five years.
Nursing Minimum Data Set (NMDS)
NMDS is not in UMLS.
1983 No
Nursing Management Minimum Data Set (NMMDS)
NMMDS is not in UMLS. However, it is fully encoded with LOINC, which is in UMLS.
1996/1997 No
Identifying Challenges and Opportunities within Standard Nursing Terminologies 8
V. Findings
A. Reference Terminologies Reference terminologies are designed to “…provide common semantics for diverse implementations” (CIMI, 2013) and ideally, they enable clinicians to use terms (synonyms) appropriate for their discipline-specific practices (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008) (Westra, et al., 2015). The mapping of interface terminologies to reference terminologies allows a standard, shared vocabulary to communicate data across settings.
The ANA-recognized reference terminologies are SNOMED CT and LOINC (characterized by the ANA as “multidisciplinary” terminologies). The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) require the use of a reference terminology (SNOMED CT and LOINC) for Meaningful Use incentive payments and for certification, respectively.
1. SNOMED CT SNOMED CT
Latest Update via UMLS 2017 Original Publications SNOMED (1975)
SNOMED II (1979) SNOMED CT (2002)
Owned and distributed by SNOMED International, SNOMED CT is a comprehensive, multilingual clinical health care terminology used in more than 50 countries. When implemented into health IT, SNOMED CT provides a multidisciplinary approach to consistently and reliably represent clinical content in EHRs and other health IT solutions. SNOMED CT is important in health IT development and implementation as it supports the development of high-quality clinical content and provides a standardized way to record clinical data that enables meaning-based retrieval and exchange (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008).
SNOMED CT content is represented using three different types of components, including concepts representing clinical meaning; descriptions that link terms to concepts; and relationships to link each concept to other related concepts. It is augmented by reference sets that support customization and enhancement of SNOMED CT, including subsets, language preferences and mapping from or to other terminologies. SNOMED CT maps provide explicit links to other health-related classifications and coding systems, e.g., to International Classification of Diseases (ICD-10).
The U.S. Edition of SNOMED CT is the official source of SNOMED CT for use in the United States and is a standalone release that combines content of both the U.S. extension and the International release of SNOMED CT. For example, the U.S. Edition of SNOMED CT contains subsets representing Clinical Observations Recordings and Encoding (CORE) Problem list subset, as well as a Nursing Problem List subset to facilitate use of SNOMED CT as the primary coding terminology.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 9
Process for Updating/Publishing Standard SNOMED International provides its members with the ability to request changes to SNOMED CT through National Release Centers (NRC) in member countries. In some cases, changes may only be implemented in a national extension. If the change has international relevance, it is forwarded to SNOMED International for consideration of inclusion in the next release cycle. A new version of SNOMED CT is released to SNOMED International members in July and in January yearly. As the U.S. member of SNOMED International, NLM distributes SNOMED CT at no cost through the Uniform Medical Language System (ULMS) Metathesaurus via a licensing program.
Usage/Activity SNOMED CT is required in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Detailed information on each edition’s specific SNOMED CT criterion requirements are in the respective regulations and referenced in the “Standards Hub” on ONC’s website: https://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub
Challenges Before SNOMED International purchased SNOMED CT from the College of American Pathologists (CAP), many ANA-recognized interface terminologies for nursing were integrated into SNOMED CT through the mapping of the nursing terms to valid concepts within SNOMED CT. However, SNOMED International did not purchase these maps from CAP, so they are not included in the international version of SNOMED CT. In addition, the NLM does not maintain mappings in the U.S. Edition as new editions are released. Therefore, any existing maps from nursing-specific terminologies to SNOMED CT would be maintained by each SNT.
Opportunities SNOMED CT has a broad scope of coverage, including concepts across a wide range of multidisciplinary clinical information while maintaining the relationships between the concepts and supporting important capabilities such as clinical decision support, quality measurement and research initiatives. With greater inclusion of nursing content, SNOMED CT could be utilized at the user interface, eliminating the need for mapping and integration with other interface terminologies.