Lecture 5 Standardized Terminology and Language in Health Care (Chapter 15)

Learning Objectives 1.Standardized healthcare terminology and its importance 2.Languages and Classifications : Billing, Clinical, Nursing 3.Terminology structures: Classification System vs. Reference Terminology 4.Benefits of using structured terminologies within electronic healthcare records. 5.Issues and concerns IS 531 : Lecture 52

Standardized Terminology Also called “Controlled Terminology” Structured and controlled languages developed and approved by an authoritative body Healthcare terminology standards designed to enable and support interoperability and information sharing Essential to the widespread implementation of EHRs IS 531 : Lecture 53

Healthcare Terminology Standards To represent, communicate, exchange, manage and report data information, and knowledge in healthcare Ensure accurate, valid data collection among various providers and care settings Meaningful Use: exchange clinical structured data in an accurate and complete manner to improve cost- efficiency in client care IS 531 : Lecture 54

Terminology Definitions... Concept: an expression with a single unambiguous meaning Code: letters/characters/both to represent a concept – Codified concepts Clinical terminology: describe health conditions and healthcare activities Ontology: concepts are organized by their meaning describe a definitional structure- relationship IS 531 : Lecture 55

...Terminology Definitions Reference Terminology: a set of concepts with definitional relationship – To retrieve data across healthcare settings, domains, and specialties Point-of-care Terminology (interface terminology): reference terminology in familiar term to clinicians – to support the entry of patient-related information into a computer program IS 531 : Lecture 56

Types of Healthcare Terminologies IS 531 : Lecture 57

8 Technology Development Guidelines

Terminology and Nursing Different terms indicate the same thing ! Need a standardized nursing language to describe care across clinical settings and specialists How to document nursing problems, interventions, and outcomes To support interoperability, sharing comparable data with other healthcare organizations IS 531 : Lecture 59

Languages and Classifications... Billing Codes – Mandated by Health Insurance Portability and Accountability Act (HIPAA) – International Classification of Disease (ICD) by World Health Organization (WHO): for diagnosis reimbursement – Current Procedural Terminology (CPT) American Medical Association(AMA): for billing and reimbursement of outpatient procedures and interventions IS 531 : Lecture 510

IS 531 : Lecture 511 ICD Examples

IS 531 : Lecture 512 CPT Examples

Languages and Classifications... Clinical Terminologies – Unified Medical Language Systems (UMLS) by National Library of Medicines (NLM), recognized by American Nurses Association (ANA) – Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT) – Logical Observation Identifiers, Name, and Codes (LOINC) IS 531 : Lecture 513

SNOMED-CT Globally recognized terminology (concepts, descriptions, and relationships) Recognized by ANA Promotes evidence-based practice Undergoes review process to keep up to date SNOMED-CT consists of 19 top-level hierarchies (Cf. p.305) Using parent-child relationship to build vertical hierarchies IS 531 : Lecture 514

IS 531 : Lecture 515 SNOMED-CT Example

LOINC “Logical Observation Identifiers, Names, and Codes” Terminologies for laboratory and clinical observations For recording a single observation, measurement, test result. IS 531 : Lecture 516

IS 531 : Lecture 517 LOINC Examples

Languages and Classifications... Nursing Terminologies – Clinical Care Classification (CCC) – International Classification of Nursing Practice (ICN) – North American Nursing Diagnosis Association International (NANDA-I) – Nursing Intervention Classification (NIC) – Nursing Outcome Classification (NOC) – Omaha System – Perioperative Nursing Data Set (PNDS) IS 531 : Lecture 518

Clinical Care Classification (CCC) System To facilitate patient care documentation at the point of care CCC of nursing diagnosis and outcome: – 182 diagnosis concepts in categories and sub- categories; 3 outcome qualifiers. CCC for nursing intervention: – 198 concepts in categories and sub-categories to represent interventions, procedures, treatments, and activities. IS 531 : Lecture 519

International Classification of Nursing Practice (ICNP) For point-of-care and reference terminology Contains diagnoses, actions, and outcomes in 7 axes (dimensions) IS 531 : Lecture 520

IS 531 : Lecture 521 ICNP Examples

NANDA-I “North American Nursing Diagnosis International” Each nursing diagnosis actual or potential health problem has: description, definition, defining characteristics (manifestations, signs, symptoms) 13 domains, 7 axes(dimensions) IS 531 : Lecture 522

IS 531 : Lecture 523 NANDA Domains

IS 531 : Lecture 524 NANDA-I Examples

Nursing Interventions Classification (NIC) Describe interventions used in nursing care 30 classes, 7 domains and 542 interventions IS 531 : Lecture 525

IS 531 : Lecture 526 NIC Domains

Nursing Outcomes Classification (NOC) Describe outcomes related to nursing interventions 31 classes and 7 domains of outcomes Each outcome has: definition, measurement scale, associated indicators, supporting references IS 531 : Lecture 527

IS 531 : Lecture 528 NOC Domains

Omaha System Research-based taxonomy for integrating and sharing clinical data Assessment component—Problem Classification Scheme Intervention component—Intervention Scheme Outcomes component—Problem Rating Scale for Outcomes IS 531 : Lecture 529

IS 531 : Lecture 530 Omaha Systems

Perioperative Nursing Data (PNDS) Set Provide wording and definitions for nursing diagnoses, interventions, and outcomes Allow collection data in a uniform way for analyses 4 components, 75 diagnoses, 135 interventions, and 27 nurse-sensitive patient care outcomes IS 531 : Lecture 531

IS 531 : Lecture 532 PNDS Example

Benefits of Implementation Client-specific benefits – Decreased costs – Increased quality – Improved outcomes – Improved safety IS 531 : Lecture 533

Benefits of Implementation Provider/Nursing Benefits – Complete access to data – Increased efficiency – Increased accuracy – Increased effectiveness – Improvement in client care IS 531 : Lecture 534

Benefits of Implementation Organizational Benefits – Decreased costs – Decision support – Outcome measurement – Data mining IS 531 : Lecture 535

Issues and Concerns Integrate systems with locally defined concepts, not using standard terminology Select which terminology(ies) to use Point-of-care terms and synonyms for clinical tasks must be locally developed: potential problems for other local systems IS 531 : Lecture 536

IS 531 : Lecture 537 Nursing Assessment Examples

IS 531 : Lecture 538 Nursing Diagnosis/Problem Examples

IS 531 : Lecture 539 Nursing Intervention Examples

IS 531 : Lecture 540 Nursing Goal/Potential Outcome Examples