Nursing Management Minimum Data Set (NMMDS) NMMDS
Latest Update via UMLS Not in UMLS Original Publication 1996/1997
The NMMDS is a uniform minimum health data set that “specifically identifies variables essential to nursing administrators for decision-making about nursing care effectiveness” (Gardner-Huber, Delaney, Crossley, Mehmert, & Ellerbe). It was developed to provide a framework for the data needs of nurse executives and provides a “…collection of core data elements needed by nurse administrators to make management decisions and compare the effectiveness of institutions” (Gardner-Huber, Delaney, Crossley, Mehmert, & Ellerbe). The NMMDS framework is guided by the work of Werley and Lang’s NMDS, the Iowa Model of Nursing Administration and Donabedian’s components for measuring quality (Gardner-Huber, Delaney, Crossley, Mehmert, & Ellerbe). The NMMDS is structured around 18 elements associated with nursing environment, nursing care resources and financial resources.
NMMDS variables of interest include, but are not limited to:
Staffing; Client/ patient population; Model of care delivery; and Type of nursing unit (Delaney, Westra, & Pruinelli, 2015).
From an activity standpoint, NMMDS can “link to and augment the other minimum health data sets by providing information uniquely important to nursing administrative decisions, and thus the evaluation of nursing services for cost and quality” (Delaney, Westra, & Pruinelli, 2015). All updated elements for the environment and nurse components are mapped to LOINC.
Process for Updating/Publishing Standard NMMDS used a descriptive survey approach as the process for the original version. The survey used a Delphi technique in order to “elicit the opinions and consensus of experts in the identification of essential elements for the NMMDS” (Delaney, Westra, & Pruinelli, 2015) (Gardner-Huber, Delaney, Crossley, Mehmert, & Ellerbe). Following the completion of the survey processes, a proposed list of 18 NMMDS elements were established. Over the years, updates have been made to the NMMDS following a similar process of the original version. The updating processes include:
Expert review panels; National Delphi surveys; Focus groups; Cross-sectional descriptive surveys; and A national consensus working conference (Huber, Schumacher, & Delaney, 1997).
The last version of NMMDS was published in 2015; there is no plan to update NMMDS in the near future.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 23
Usage/Activity NMMDS has not achieved widespread usage.
Challenges unknown
Opportunities NMMDS has the potential to provide nurse executives access to important data for decision-making and benchmarking of services across care delivery settings, which contributes to both quality and outcomes of care. The implementation guide is available online (Delaney, Westra, & Pruinelli, 2015).
VI. Health IT Developers – Perspective
To gain an additional perspective on usage of SNTs within health IT, the project team surveyed three EHR developers, using the questionnaire in Appendix C, sampled from those serving the acute care nursing domain. Developers were chosen at the discretion of the contract team generating the report and although anonymity was not a requirement for discussion with the project team, the comments from vendors have been blinded and collated for the purposes of this report. Discussions focused on understanding how SNTs are used within each developer’s software applications, the process used to implement any SNT, and the benefits and challenges of implementation and usage of SNTs. Identified themes are highlighted below:
Mapping and the maintenance of maps is a resource-intensive endeavor. Some customers employ third-party resources to maintain their terminology mappings. Many facilities have a clear lack of mapping expertise.
Most vendors do not align with a single SNT due to customer requests for customization and varying nursing leadership philosophies on SNTs. Due to the ONC certification requirement, most workflows and clinical content are mapped to SNOMED CT and LOINC.
Developers try to find balance between offering customization options and providing data standardization and mapping. The variability across nursing standards makes basic integration with EHRs difficult, and developers must maintain flexibility in the marketplace, with regard to customer requests for customization. o One vendor gave a specific example of how customized documentation affects the ability of
an organization to retrieve data, citing a facility that customized more than 200 forms without mapping any data elements SNOMED CT or LOINC. Although the forms are highly specific to a care setting or patient population, no data mining is possible with those forms in their current state.
Licensing fees represent a barrier to the widespread distribution of some terminologies through a vendor platform.
Some customers find the language in some terminologies awkward and difficult to implement; this becomes more apparent as customers move to implement an interdisciplinary care plan and other types of clinical documentation.
Some assessment scales have copyrights and fees associated with use. This is reported to be a barrier for customers and makes it difficult to standardize assessment data across settings.
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Often, facility-specific customization affects widespread data mining efforts. Although data may be usable for a single facility, it is difficult to interconnect this system to other systems. One vendor referred to clients being “data rich but information poor.”
VII. Emerging Issues in Using SNTs
Standardization is critical for sharable, comparable data needed to effectively deliver care and conduct research. Our analysis identified the need for a common language that captures the nursing process, including actions and outcomes to determine the contribution of nurses to good quality and outcomes across care settings. Although some facilities have mapped nursing content to one or more SNTs in their electronic health records, a lack of harmonization across standards inhibits the goal of interoperable, shared data that moves with the patient across care settings.
With regard to nursing documentation and content, multiple nursing assessment scales exist to represent the same concepts. The lack of standardized assessment tools and forms make it difficult for software developers and their customers to standardize their clinical content. Most EHR developers report that lack of standardization in their products results from lack of harmony and agreement in field. All three developers interviewed agreed they would welcome the adoption of standardized nursing content and would prefer this to the individual client site customizations that affect interoperability as well as data integrity and validity.
A lack of data standardization in nursing content, and clinical content in general, exists within many installed electronic health record sytems. Sometimes this lack of standardization is due to customer demands for customized content. It could also demonstrate the need to perform “spring cleaning” (Effken & Weaver, 2016) of longstanding nursing documentation that does not provide value. Problematic customization may include the deployment of unique data elements or non-standard, non- mapped vocabularies to meet local preferences or prior practices, rather than using standard clinical data element templates linked to specific terminologies. Individual facilities may also fail to deploy templates with robust and effective user-centered design of the user interface and workflows in juxtaposition with the clinical care workflow. Finally, different customers often prefer one SNT to another; it is difficult to obtain agreement across a software developer’s customer base on the use of a single standardized terminology.
The variation currently seen negatively affects the ability to share clinical data across settings of care in a meaningful way to ensure safer, better care for patients or to use the data for analytics. It also affects the accuracy of clinical quality measures and outcome analysis.
The process of mapping local content to reference terminologies, specifically SNOMED CT and LOINC, is a resource-intensive one. Whether mapping is performed and maintained by the software developer, a third-party vendor or the individual health care organization, the process is complex and carries a cost burden. It also requires clinical “informaticists” with deep expertise and proficiency as experts with the
1. Lack of Alignment on Terminology Standards for Nursing Content Definition
2. Customized Development and Implementation of EHR Systems