Minnesota Recommendation to Use of a Standard Nursing Terminology in All Health Care Settings Bonnie L. Associate Professor & Director Center for Nursing Informatics, University of Minnesota, School of Nursing

2 Vision for Nursing Data in an Electronic Health Record Supported Clinical Data Warehouse Clinical Data NMDS Management Data NMMDS Other Data Sets Continuum of Care Nursing Clinicians Students/ Faculty Researchers Practice Evaluation & Quality Health Policy Professional organizations

3 Westra, B.L., Delaney, C.W., Konicek, D., & Keenan, G. (2008). Nursing Standards to Support the Electronic Health Record. Nursing Outlook, 56, e1

4 Use of Nursing Terminologies Data Sets – Big Picture User Interface Health Information Exchange

5 NMDS NMMDS (clinical)(management) Patient Demographics –Date of birth –Race/ Ethnicity Nursing Care Elements –Nursing Dx –Interventions –Outcomes Service Elements –Unique Number of Principal Registered Nurse Provider –Discharge or Termination Date * Environment –Type of nursing delivery unit/service –Method of care delivery Nursing Care Resources –Management demographic profile –Staffing Financial Resources –Payer type –Reimbursement

User Interface Terminologies NNN –NANDA - North American Nursing Diagnosis Association –NIC - Nursing Interventions Classification System –NOC Nursing Outcomes Classification System CCC - Clinical Care Classification ICNP - International Classification of Nursing Practice Omaha System PNDS - Perioperative Nursing Data Set 6

7 Health Information Exchange Logical Observation Identifier Names & Codes (LOINC®) –Assessments Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT) –Diagnoses/ Problems –Interventions –Outcomes

INTEROPERABILITY

Minnesota e-Health Initiative A public-private collaboration established in 2004  Legislatively chartered  Coordinates and recommends statewide policy on e-Health  Develops and acts on statewide e- health priorities  Reflects the health community’s strong commitment to act in a coordinated, systematic and focused way 9 “Vision: … accelerate the adoption and effective use of Health Information Technology to improve healthcare quality, increase patient safety, reduce healthcare costs, and enable individuals and communities to make the best possible health decisions.”

Minnesota Recommendation 1.All health and health care settings should create a plan for implementing an (ANA) recognized terminology within their (EHR). 2.Each health and health care setting type should achieve consensus 3.Education should be provided and guidance be developed for selecting the terminology

Minnesota Recommendation 1.When exchanging a Consolidated Clinical Document Architecture (C-CDA) document with another setting for problems and care plans, ise SNOMED-CT and LOINC 2.The Omaha System be used for exchange between public health or community- based settings if both use the same terminology

Next Dr. Karen Monsen will report on the current state of nursing terminology implementation Break into groups and brainstorm 3 actions to achieve the recommendation Report back