Page 1 of 20 Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care By Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions; Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas; Jane Brokel, PhD, RN, NANDA International; Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification; Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification; Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification; Marion Johnson, PhD, RN; Nursing Outcomes Classification; Meridean Maas PhD, RN; Nursing Outcomes Classification; Karen S. Martin, RN, NSN, FAAN; Omaha System; Sue Moorhead PhD, RN, Nursing Outcomes Classification; Christine Spisla, RN, MSN; SNOMED Terminology Solutions; Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification, Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf Page 2 of 20 Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs. Key Words: Nursing Terminology, Standardized nursing terminology, NANDA International, Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT) Introduction The care nurses provide to variety of care settings. Selecting the sustain life, enable recovery, appropriate nursing terminology alleviate suffering and promote implementation for use in the EHR health should be captured within the can be daunting. electronic health record (EHR). To This article will highlight share this information between selected American Nursing clinical disciplines and care settings, Association’s (ANA) recognized data needs to be recorded and stored nursing terminologies and their in a standardized form. relationships to each other. This Terminologies are one way to ensure discussion will assist in making standardization so patient care data decisions about the combination of can be stored in an unambiguous nursing terminologies that best fit way. Nursing has numerous your organization’s practice and terminologies, each developed for a requirements for the EHR. Benefits of Implementing Standardized Terminologies within Electronic Health Records Standardized nursing benefit by being able to measure terminologies provide benefits to nursing care and its impact on the patient, the organization, the patient care through queries of the nursing profession, and each patient record instead of costly country. Patients benefit from manual chart audits. This continuity of care being facilitated determination of nursing’s impact is through the use of standardized essential to validating the terminologies through improved contribution of nursing to and unambiguous communication healthcare and patient safety. between clinicians. Organizations Furthermore, the organization Page 3 of 20 benefits from the use of standard reveal the impact of nursing care terminologies by providing through electronic means (Weaver, administrators with the actual costs Warren, & Delaney, 2005). Each and benefits of nursing care. Then country benefits by having informed decisions can be made retrievable coded data that can be regarding staffing ratios. This aggregated into informative reports strategy has been useful for or data sets. These reports allow physicians using the Common countries to compare nursing’s Procedural Terminology (CPT contribution to care both nationally codes) for billing purposes and internationally using the (Giannangelo & Fenton, 2008). International Nursing Minimum Nurse educators use standardized Data Set. (Goosen, et al, 2006). terminologies in the curriculum to The standardized nursing teach nursing concepts that are terminologies, recognized by the critical in the nursing process and American Nursing Association are vital to developing new nurses (ANA), are the vehicles for the (Warren, Connors, & Weaver, aggregation of nursing data 2002). The registered nurse benefits recorded in EHRs which can be from the use of standardized used to improve quality of patient nursing terminologies to facilitate care and patient safety. critical thinking and decision Giannangelo and Fenton (2008) making at the point of care state that EHRs “must use (Dochterman, Titler, Wang, & consistent, codified terminology to Reed, 2005). The nursing eliminate ambiguity, confusion, and profession benefits from being ensure data correctness and provided a means to document, interoperability…standardized store, and retrieve evidence-based terminologies identify the discrete practice in a semantic way to structured data that allow data facilitate nursing research and capture and processing (p. 29).” American Nursing Association Recognized Terminologies The ANA Committee for vocabulary that supports nursing Nursing Practice Information and are clinically relevant for the Infrastructure (CNPII) has defined nursing domain. The terminologies specific criteria used to recognize need to possess clear and standardized terminologies. These unambiguous concepts with a criteria are foundational to the coding scheme containing one standardization of nursing unique identifier per concept. The documentation and verbal terminologies must contain communication that will lead to a documented testing of reliability, reduction in errors and an increase validity and clinical usefulness in in the quality and continuity of care practice to become recognized (American Nursing Association (American Nursing Association [ANA], 2006, 1). The ANA criteria [ANA], 2006, 1). The ANA require that terminologies possess recognized nursing terminologies Page 4 of 20 are listed in alphabetical order in Table 1. Table 1: ANA recognized terminologies ANA Recognized Terminology URL Nursing Process Date Integrated Terminologies within Terminology Recognized by Within Other the ANA Terminologies CCC http://www.sabacare.com/ Diagnoses, Clinical Care Interventions, and Classification Outcomes ICNP International http://www.icn.ch/icnp.ht Diagnoses, Classification of m Interventions, and Nursing Practice Outcomes NANDA www.nanda.org Nursing Diagnoses 1992 NLM- UMLS NANDA SNOMED CT International PNDS HL7 NIDSEC NIC www.nursing.uiowa.edu/c Interventions 1992 NLM- UMLS Nursing nc SNOMED CT Intervention HL7 Classification NIDSEC ABC Codes NOC www.nursing.uiowa.edu/c Outcomes 1998 NLM- UMLS Nursing Outcome nc Indicators SNOMED CT Classification HL7 NIDSEC Omaha System www.omahasystem.org Problem 1992 NLM- UMLS Classification Scheme SNOMED CT Intervention Scheme HL7 Problem Rating Scale NIDSEC for Outcomes LOINC ABC Codes PNDS www.aorn.org/PracticeRe Diagnoses, 1999 NLM- UMLS Perioperative sources/PNDS Interventions and SNOMED CT Nursing Data Set Outcomes HL7 SNOMED CT httpwww.cap.org/apps/ca Assessment concepts, 2002 NLM- UMLS Systematic p.portal? Diagnoses, Nomenclature of _nfpb=true&_pageLabel= Interventions, and Medicine Clinical snomed_page Outcomes Terms Page 5 of 20 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) SNOMED CT is a concepts and relationships used comprehensive, scientifically precisely in recording and validated clinical terminology and representing clinical information infrastructure for healthcare across the scope of healthcare. containing a broad coverage of SNOMED CT is concept-based, terminology supporting healthcare meaning each concept has a distinct documentation through the definition and a unique code continuum of care. SNOMED CT identifier. SNOMED CT consists of provides a consistent way of 19 top-level hierarchies, e.g.: indexing, storing, retrieving and procedures (medical and surgical aggregating clinical data across procedures, laboratory and specialties and sites of care. The use radiology procedures, interventions, of SNOMED CT within electronic education and management health records provides interoperable procedures), clinical findings, data extraction and analysis that can (nursing diagnoses, disorders, be shared across clinicians, clinical diseases that are necessarily settings and organizations both abnormal, clinical observations and nationally and internationally.