1. M8120 Data for Evidence-based Practice Fall 2001

2. Outline Background Nursing terminologies Other standardized terminologies Concept-oriented terminologies Model testing –Interventions –Assessments –Diagnoses Standardization initiatives Impact of concept-oriented terminologies

3. Foundation for Evidence-based Practice Standardized terminologies Digital sources of evidence Standards that facilitate health care data exchange Informatics competencies Informatics processes that support the acquisition and application of evidence to a specific clinical situation

4. What Data Do We Need for Evidence-Based Practice? Data and information about the patient Data and information about the context of care Domain information and knowledge (“the evidence”) from systematic inquiry and other sources

5. Standardized Terminologies Capture and store patient care data (including context of care) in a standardized fashion Facilitate data re-use and aggregation Index information and knowledge resources (“the evidence”) Facilitate information retrieval

6. Standardized Terminologies System Problem/Dx Interventions Outcomes NANDA Taxonomy 1x Current Procedural Terminologyx Nursing Interventions Classificationx Omaha Systemxxx Home Health Care Classificationxxx International Classification of Diseasesx SNOMED Clinical Termsxxx Nursing Outcomes Classificationx Medcinxxx First Data Bank Pharmacy KBxx

7. Background Nursing Minimum Data Set –Nursing diagnoses –Nursing interventions –Nursing-sensitive outcomes –Nursing care intensity –Primary nurse –+ others not specific to nursing

8. Nursing Systems Diagnoses/judgments –NANDA Taxonomy I –Georgetown Home Health Care Classification –Patient Care Data Set –Omaha System –International Classification of Nursing Practice

9. Nursing Systems Interventions –Nursing Interventions Classification –Georgetown Home Health Care Classification –Patient Care Data Set –Omaha System –International Classification of Nursing Practice

10. Nursing Systems Outcomes –Nursing Outcomes Classification –Georgetown Home Health Care Classification –Omaha System –International Classification of Nursing Practice Goals –Patient Care Data Set

11. Nursing Interventions Classification Three-tiered taxonomy –7 domains (e.g., Health System) –30 classes (e.g., Health System Management) –486 interventions (e.g., Critical Path Development) – Plus related activities (e.g., Review current standards of practice related to patient population)

12. Home Health Care Classification 20 care components 145 nursing diagnoses Interventions –161 interventions (e.g., Wound Care) –4 modes of nursing action - assess, care, teach, manage Outcomes –Stabilized, deteriorated, improved

13. Patient Care Data Set Care Components - 22 –Pre-, Intra-, or Post-Procedure Problems - 363 –Cardiac electrophysiology alteration Patient Care Orders - 1357 –Teach and encourage to use stress management techniques Patient Goals - 308 –Patient will maintain or achieve hemodynamic stability

14. International Classification of Nursing Practice (ICNP) Product of the International Council of Nurses Phenomena Nursing actions Nursing-sensitive patient outcomes

15. Other Important Standardized Terminologies International Classification of Diseases Physician’s Current Procedural Terminology SNOMED Clinical Terms Logical Observations, Identifiers, Names, and Codes (LOINC)

16. Issues Related to Standardized Terminologies Multiple terminologies exist Large number of terms Terms vary in level of abstraction Areas of overlap Areas of gap “Computability”

17. Potential Solutions Uniform language Unified Medical Language System Concept-oriented “reference” terminologies

18. What is the UMLS? Long-term NLM research and development effort designed to facilitate the retrieval and integration of information from multiple machine-readable biomedical information sources Includes development of machine-readable “knowledge sources” that can be used by a wide variety of application programs to compensate for differences in the way concepts are expressed in different machine-readable sources and by different users

20. Contents Metathesaurus Specialist Lexicon Semantic Network Information Sources Map

22. Metathesaurus Semantic information about biomedical concepts, their various names, and the relationships among them Built from source vocabularies, i.e., thesauri, classifications, coding systems, and lists of controlled terms that are developed and maintained by different organizations 476,313 concepts and 1,051,901 different concept names from >40 source vocabularies

23. Organization of Metathesaurus Organized by concept (meaning) Concept unique identifier (CUI) - identifier linked to each concept String unique identifier (SUI) - identifier for each unique concept name or string Lexical unique identifier (LUI) - links all lexical variants

24. Organization of Metathesaurus Concepts (CUIs) Terms (LUIs) Strings (SUIs) C0004238 L0004238 S0016668 Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Atrial Fibrillations Atrial Fibrillations S0016669 Auricular Fibrillation L0004327 Atrial Fibrillations Auricular Fibrillations Auricular Fibrillation S0016899 Auricular Fibrillations Auricular Fibrillation S0016900 Auricular Fibrillations

29. Major Use Interface - optimized for user data entry Administrative - optimized for statistical classification Reference - optimized for non- ambiguous concept definition, information retrieval, and analysis

30. What is a Concept-Oriented Terminology? Focus on concept (unit of thought) rather than on term (linguistic expression) Terminology in which the concepts are formally represented in a manner that renders them suitable for computer processing Optimized for computer vs. human processing (understanding) Reference terminology as compared to an interface or administrative terminology

31. Concept-OrientedSymbolObject Concept

32. Formal Definition of Concepts NOC - Knowledge: Breastfeeding Lexical definition –Extent of understanding conveyed about lactation and nourishment of infant through breast feeding Formal definition Has component NOC.KNOWLEDGE:BREASTFEEDING Has property FINDING Has sample PATIENT/CLIENT Has timing POINT Has scale ORDINAL Has method OBSERVED

33. Optimized for Computer Processing Processing on meaning (semantics) rather than structure (syntax) NOC - Knowledge: Breastfeeding Has component NOC.KNOWLEDGE:BREASTFEEDING Has property IMPRESSION Has sample PATIENT/CLIENT Has timing POINT Has scale ORDINAL Has method OBSERVED IS-A KNOWLEDGE MEASUREMENT IS-A BREASTFEEDING MEASUREMENT

34. What Do We Gain by Building a Concept-Oriented Terminology? Enhanced retrieval of data at varying levels of abstraction Improved ability to aggregate and compare data across representations –Mapping from interface to administrative terminologies –Mapping among interface terminologies –Mapping among administrative terminologies Version control and terminology evolution over time

35. Examples of Concept-Oriented Terminology Systems GALEN Logical Observations Identifiers, Names, and Codes (LOINC) Medical Entities Dictionary (The MED) SNOMED RT

36. What Does It Take to Build a Concept-Oriented Terminology? Terms with codes to provide “values” for concepts in the models Terminology model Representation language Software for processing

37. Status of Components in Nursing Terms with codes to provide “values” for concepts in the models - many Terminology model - evolving Representation language - generic Software for processing - generic

38. Terminology Model Explicit representation of a system of concepts that is optimized for terminology management and that supports the intensional definition of concepts and the mapping among terminologies A terminology model depicts the associative relationships between an aggregate (molecular) expression and more primitive (atomic) concepts Type definition - attributes (properties, roles) necessary and sufficient for non-ambiguously defining a concept of a particular type (fully specified name)

39. Example Diabetic foot care - Teach Type definition for nursing activity concept –Action TEACH –Target DIABETIC FOOT CARE –Recipient of care PATIENT

40. Representation Language Description logics based on predicate calculus represented in different formalisms –Predicate calculus –Conceptual graphs (e.g., KRSS) –GRAIL Vary in expressibility and parsimony

41. Software for Processing Formal and automated classification (IS-A relationships) of new concepts Inheritance of attributes of parent concepts to facilitate formal definition of child concepts Rules (grammar) for generation of composite concepts Natural language generation (GALEN) Conflict resolution management for distributed development (SNOMED RT)

42. Examples l GALEN l SNOMED RT

43. GALEN

44. What Does the Box Need to ‘Know’? How to classify things Sensible combinations Redundant information etc...

45. GRAIL RelievingPain actsOn (Relieving which actsOn Pain) name RelievingPain

46. Symptom actsOn Pain Relieving Relieving which actsOn Symptom Relieving which actsOn Pain GRAIL - Formal Subsumption

47. Injecting which < actsOn Medicine hasMeans Syringe> GRAIL - Normalization Injecting which< actsOn Medicine> Injecting which< actsOn Medicine>

48. Injecting Interviewing Treating Glass eye Medicine Person Hypnosis Syringe Representing ICNP in GRAIL

49. Mapping to ICNP Tube care: Gastrointestinal NIC 2.A.-4.Caring 2.B.-2.1.3.Tubes 2.E.-1.1.13.Gastrointestine ICNP

50. GRAIL - Classification Caring which < hasPersonPerforming Nurse actsOn (Tubes which hasLocation Gastrointestine> ‘Nursing Interventions Taking As Object Other Objects’ ‘Nursing Interventions With Reference To: Anatomical Locations’

51. Benefits of Compositional Approach Definitions are made explicit –Utilizes underlying concepts to manage model Multiple classification –Supports dynamic reorganization Naturalistic language generation –Hide syntax from users

52. GRAIL - Language Generation Caring which < hasPersonPerforming Nurse actsOn (Tubes which hasLocation Gastrointestine> ‘Caring for tube, gastrointestine’

53. GRAIL - Mediation between Representations HHCC Acute pain Pain NANDA Symptom Pain Pain which hasChronicity acute GRAIL

54. Nursing Intervention performance IS MODALITY OF an action IS PERFORMED BY nurse person PLAYS ROLE nurse role

55. Preoperative Coordination performance IS MODALITY OF coordinating IS PERFORMED BY nurse OCCURS preoperatively

56. Bottle Feeding performance IS MODALITY OF feeding IS PERFORMED BY nurse HAS MEANS bottle

57. SNOMED RT Optimized for retrieval and analysis of data relating to the causes of disease, treatments of patients, and outcomes of the overall health care process Based on SNOMED International Provider-neutral representations Evolving toward SNOMED Clinical Terms

58. SNOMED RT Includes: –Representation language - modified KRSS –Computer-based tools (Galapagos, Ontylog, Metaphrase) Missing for nursing: –Terms with codes to provide “values” for concepts in the models –Categorical structures

59. Representation Language l Example: Postoperative esophagitis l SNOMED RT syntax D30150: D5-30100 & ( assoc-topography T-56000) & ( assoc-morphology M-40000) & (assoc-etiology F-06003)

60. Terminology Model Development and Validation Efforts Nursing activity example International Standards Organization SNOMED Convergent Terminology Group for Nursing Nursing Terminology Summit

61. Standardized Terminologies with Terms for Nursing Activity Concepts Nursing Interventions Classification Home Health Care Classification Omaha System Patient Care Data Set AORN Perioperative Nursing Data Set SNOMED RT NHS Clinical Terms International Classification of Nursing Practice

62. Study Purpose Evaluate the adequacy and utility of a type definition (required parts of a terminology model) for nursing activities Research Questions –What percentage of nursing activity terms includes the attributes of the type definition (Delivery Mode, Activity Focus, and Recipient)? –Can the nursing activity terms be reliably decomposed into the three attributes of the type definition?

63. Definitions Activity - intentional service delivered by a provider to a recipient (e.g., wound care provided by a nurse, grief counseling provided to a family)

64. Definitions Delivery Mode - manner in which the activity is applied to the recipient (e.g., assess the patient for shortness of breath, coordinate the delivery of Meals on Wheels) Activity Focus - phenomenon upon which the activity is centered. Activity Focus can be a medical or nursing diagnosis, sign, symptom, problem or health issue (e.g., pain, inadequate knowledge) Recipient - person, family, organization, or aggregate to whom the activity is delivered. The patient is the implicit recipient of all activities unless otherwise specified (e.g., apply sterile dressings to wound [patient]; teach the caretaker transferring precautions)

65. Data Sets Chart terms (Interface) Home Health Care Classification (Interface and Administrative) Omaha System (Interface and Administrative)

66. Chart Terms 1039 non-redundant nursing activity terms Health records of >300 persons hospitalized for AIDS-related condition Verbatim abstraction

67. Procedures Each nursing activity term decomposed into the three elements of the type definition –Delivery mode - identified and coded as Explicit or Implicit –Recipient - categorized as Explicit, Implicit, or Ambiguous Multiple raters - trained on subset with one rater serving as gold standard Coded as containing the three elements of the type definition if: –Delivery mode = Explicit –Activity focus = Present –Recipient = Non-ambiguous (Implicit or Explicit)

68. Examples: Chart Terms Assess family knowledge –Delivery mode - Assess (Explicit) –Activity focus - Knowledge level (Present) –Recipient - Family (Explicit) –Contains 3 elements of type definition - Yes Notified MD –Delivery mode - Notified (Explicit) –Activity focus - Absent –Recipient - MD (Explicit) –Contains 3 elements of type definition - No Oxygen administration –Delivery mode - Administer (Explicit) –Activity focus - Oxygen (Present) –Recipient - Patient (Implicit) –Contains 3 elements of type definition - Yes

69. Examples: HHCC Blood pressure - Assess –Delivery mode - Assess (Explicit) –Activity focus - Blood pressure (Present) –Recipient - Patient (Implicit) –Contains 3 elements of type definition - Yes Coping support - Teach –Delivery mode - Teach (Explicit) –Activity focus - Coping support (Present) –Recipient - Patient or Family (Ambiguous) –Contains 3 elements of type definition - No Medication administration - Direct care –Delivery mode - Direct care (Explicit) –Activity focus - Medication administration (Present) –Recipient - Patient (Implicit) –Contains 3 elements of type definition - Yes

70. Frequencies of Attributes of Type Definitions

73. Discussion Majority of chart terms contained elements of the type definition –Reliably decomposed Type definition had utility as a model for decomposing HHCC and Omaha –Activity focus and Delivery mode decomposition straightforward and easily reproducible –Recipient more frequently ambiguous than in chart terms –Inter-rater reliability lower for recipient

74. International Standards Organization (ISO) Initially approved as a New Work Item then resolution made by CEN & ISO to request re-submission of the New Work Item Proposal under the Vienna Agreement 5.1 with an ISO lead

75. Scope of the Proposal This New Work Item will integrate existing work and work in progress to establish a nursing terminology model consistent with the goals and objectives of other specific health terminology models and provide a more unified reference health model.

76. Structure Steering Committee Technical Committee Expert Committee

77. Steering Committee The Steering Committee is responsible for project management including the development and monitoring work processes and timelines. Members –Virginia Saba, EdD, RN, FAAN (Chair of IMIA/NI-SIG & Chair of the IMIA/NI-SIG Concept Representation Group) –Evelyn Hovenga, PhD, RN (Outgoing Chair of the IMIA/NI- SIG) –Kathleen McCormick, PhD, RN, FAAN (Chair of the Data Standards Working Group, IMIA/NI-SIG) –Amy Coenen, PhD, RN, CS (Representative from the ICN and Director of the ICNP ® )

78. Technical Committee Responsible for preparing a draft standard using input from all participants. Revise the proposal as needed based on feedback and testing. Members of this group will be selected by the Steering Committee and will not exceed one person per country. Members –Suzanne Bakken (USA) (Facilitator) –Kathryn Hannah (ISO Representative, Canada) –Nicholas Hardiker (UK) –Heimar R. Marin (Brazil) –Randi Mortensen (Denmark) –Hyeoun-Ae Park (ISO Representative, Republic of Korea)

79. Expert Committee Responsible for providing input on standard development and review of draft proposals. This group will include expert volunteers from ISO and others willing and interested in participating in the process.

80. Terminology Model Explicit representation of a system of concepts that is optimized for terminology management and that supports the intensional definition of concepts and the mapping among terminologies A terminology model depicts the associative relationships between an aggregate (molecular) expression and more primitive (atomic) concepts

81. Reference Terminology Model for Nursing Diagnoses

82. Example Activities of daily living alteration –Alteration Has potentiality qualifier: Actual Is applied to: Activities of daily living Has subject of information: Client

83. Reference Terminology Model for Nursing Actions

84. Example Pressure ulcer assessment –Assessing Acts on: pressure ulcer (target) Has subject of information: client (implied)

85. Conclusions ISO standard for a reference terminology model for nursing will support the mapping among nursing terminologies Must be integrated within a broader health care terminology model

86. SNOMED Convergent Terminology Group for Nursing Members –SNOMED International Editorial Board Member –SNOMED staff –ANA liaison –CMT nurse modelers –Nurse consultant Activities –Developing and testing models –Outreach and education –Collaboration agreements with ANA-recognized terminology developers –Participation in standards efforts

87. Nursing Terminology Summit Consensus development Think tank Constituencies –Terminology developers –System implementers –Standards experts Focus –Reference terminology model –CEN/ISO –Clinical templates

88. Impact of Concept-Oriented Terminologies Medical Entities Dictionary –Concept-oriented terminology –Meta-data dictionary for applications at New York Presbyterian Hospital