1. Standardized Terminologies and Vocabularies in Nursing
NURS 736: Technology Solutions for Knowledge Generation in Healthcare

2. Objectives
Discuss the need and motivation behind the development of standardized terminologies for nursing.
Compare and contrast existing nursing taxonomies and vocabularies.
Explore current efforts to represent nursing language.

3. Why Standards?
“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they could be obtained they would enable us to decide many other questions besides the ones alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good.”
This is by Florence Nightingale in her famous “Notes on a Hospital”. Although this was written in 1873, long before the advent of computers, we can easily identify with what she is saying. It is outcomes and effectiveness research!
<READ>
So here we are, nearly 140 years later, still unable to compare records.
We, as providers need access to data and information and our patients cannot afford fragmentation, redundancy and poor decisions due to our inability to harness our data.
F. Nightingale, 1873; Notes on a Hospital

4. Why Standards? Benefits Challenges Common meaning
Common way to communicate information
Common way to collect and aggregate data
Challenges
Computers can not interpret meaning
In aggregate data it is hard to determine meaning
Culture and language barriers
Lack standards that consistently represent nursing
Lack standards to harmonize with other terminologies
Lack consistency in how implemented in computer systems

5. Current Issues Clinical information recorded is idiosyncratic
Inconsistent & irregular formats
Redundancy of data (same data collected by different providers, recorded in different places)
Concept representations are different between clinicians, payers, administration, & researchers
Today’s environment requires tight linkage of clinical, resource, & cost data
APC (prospective payment for ambulatory care) requires coding and connectivity
Must have rich clinical clarity to improve outcomes

6. Current Issues Why can’t we do this with claims databases?
Incomplete & unreliable
Emphasis on coding & sequencing diagnosis & treatments for reimbursement
Outcomes research requires detailed care data
Doesn’t capture the ANA 6 stages of the nursing process - assessment, diagnosis, planning, intervention, evaluation, & identification of outcomes

7. Current Issues Why can’t you do this with claims databases?
Coding guidelines vary by payer & only cover information related to current admission
H&P data not generally included (family hx, lifestyle)
Severity adjustment drawn from claims databases
missing co-morbid conditions
Risk measurement drawn from claims databases
missing critical variables

8. Current Issues Hammond (1997)
Existing controlled language vocabularies do not meet requirements for clinical data representation
no set created for representing clinical data
many are proprietary
motivation is low
data must be at atomic level and “raw”
non-redundant and non-ambiguous
we are approaching the problem backwards

9. We cannot manage what we cannot measure.....
Because we cannot manage what we cannot measure.

10. What is Needed Set of standardized atomic-level terms
Hierarchical & multi-axial taxonomy
Formal semantic grammar (combinatorial rules for atomic into complex)
Expressible in non-ambiguous manner using recognized knowledge formalisms

11. Standardized Nursing Terminologies & Vocabularies
Nursing terminologies allow us to consistently capture, represent, access, and communicate nursing data, information, and knowledge. There are many nursing terminologies, formal and informal, but currently there isn’t one that meets the needs of all nursing specialties – yet! Is One Taxonomy Needed for Health Care Vocabularies and Classifications?
Click on title to read article

12. Ingenerf (1995) Typology of Languages
Thesauri
First level “lexical” vocabulary such as the UMLS Metathesaurus
List of terms from the domain - MeSH terms
Classification Systems
Class or category of words often represented by hierarchies or decision trees
International Classification of Diseases (ICD or CPT code); NIC, HHCC, Omaha Systems
Nomenclatures
Vocabularies combined with other vocabularies but rules for sensible combination are missing
SNOMED; International Classification of Nursing Practice (ICNP)
Formal Terminologies
Vocabularies with explicit rules for sensible composition
Represented using knowledge formalisms like conceptual graphs
GRAIL, Kaiser Permanente Convergent Medical Terminology, SNOMED RT/CT

13. Nursing Minimum Data Set
Background
Need identified by Werley (1970’s)
NMDS is a collection of data for comparison of care across settings and other factors (Hebda & Czar, 2009)
Four (4) Nursing Care Elements:
Diagnosis, Intervention, Outcome, Intensity
Five (5) Client Demographic Elements:
ID, Sex, Race, Date of Birth, Residence
Seven (7) Service Elements:
RN Provider #, Health Record #, Facility #, Payer, Patient disposition, Admit/Encounter Date, Discharge Date
Challenge was how to represent diagnosis, intervention, outcomes, and intensity (acuity)?
It all started with the Nursing Minimum Data Set

14. Advent of Nursing Languages
NMDS was the umbrella for other nursing data sets and classification systems listed here:
NANDA
NIC
NOC
Omaha
HHCC
ICNP-UNLS
AORN-PND
Patient Care Data Set
Click on the initials to discover the full name and learn more about each language

15. SNOMED – RT/CT
Systemized Nomenclature of Human and Veterinary Medicine (SNOMED)
Developed by College of American Pathologists
Clinical Terminology (CT) version
consists of the clinical findings module
30 categories
35404 terms that support nursing assessments
SNOMED did not start out as a nursing language but was developed for pathologists to code findings from tissue specimens. This has expanded into other areas of medicine and now includes clinical categories under consideration for nursing.

16. Current Efforts to Represent Nursing Language
UMLS – Unified Medical Language System
not a vocabulary, instead a mapping system between major classification systems
foci - medical diagnosis, treatments, notes, contains ANA approved systems
UNLS - Unified Nursing Language System
to cross-link nursing classification systems
ANA Steering Committee on Databases tasked with identifying coding systems that support development of the UNLS (8 at present). NIDSEC.