This summer, I attended two nursing informatics conferences, the 11th International Congress on Nursing Informatics (NI2012) and the Summer Institute of Nursing Informatics (SINI). At the conferences and in anticipation of the final rule of Meaningful Use Stage 2, there was a lot of discussion surrounding the topic of standard terminologies. As someone who lives and breathes terminologies, I am often asked about implementing nursing terminologies and which “one” to use. Before answering that question, let’s review the status and use of nursing terminologies in relation to national standards.
The Office of the National Coordinator (ONC) has proposed standard terminologies for multiple domains and designated certain terminologies for Stage 1 and Stage 2 of Meaningful Use.1 However, the ONC has not designated one standard terminology in the area of nursing documentation.
The American Nurses Association (ANA) recommends that nurses document according to the nursing process within the patient’s record:
They have recognized 12 nursing terminologies. Two are the multi-disciplinary LOINC and SNOMED CT terminologies. Seven are nursing specific and created specifically for documenting all or part of the nursing process within electronic health records (EHRs): Clinical Care Classification System (CCC), Omaha System, International Classification of Nursing Practice (ICNP), PeriOperative Nursing Data Set (PNDS), NANDA-I, Nursing Intervention Classification (NIC), and Nursing Outcomes Classification (NOC). The final three (Alternative Billing Codes, Nursing Management Minimum Data Set, Nursing Minimum Data Set) are used for billing or as a data set.
In addition to the ANA, other governing bodies have recommended standard terminologies for nursing documentation. The National Committee on Vital and Health Statistics (NCVHS) as well as the recently defunct Healthcare Information Technology Standards Panel (HITSP), selected SNOMED CT and LOINC.
LOINC contains the actual point-of-care observations used in nursing practice, such as pain assessment and vital signs. These can be used to trigger the identification of a nursing diagnosis. For example, if pain severity is 9 on a 1-10 scale, the patient most likely needs a nursing diagnosis of Actual Pain. The linkage between the actual observation and the nursing diagnosis as well as additional interventions and goals, is not coded or easily implementable at this time.
The nursing working group of SNOMED CT has assembled a nursing problem list subset of SNOMED CT. This problem list can be used as the nursing diagnosis within the problem list applications of EHRs as well as the problem list required for meaningful use. It was created by querying the NLM metathesaurus and identifying all the nursing diagnoses that map to SNOMED CT. This list has a cross-walk to the other nursing terminologies within the UMLS and is freely available on the National Library of Medicine (NLM) website.
Unfortunately, nursing interventions and outcomes are not as easy to aggregate into a succinct subset. Different nursing terminologies use variable methods to code and calculate interventions and outcomes. The International Council of Nursing (ICN) represents 136 countries across the globe. They have developed the International Classification of Nursing Practice (ICNP) that includes nursing diagnosis, nursing interventions and nursing outcomes.
At NI2012, ICN announced an agreement between ICNP and CCC to create a mapping between the two. The ICNP terminology complies with the ISO (International Organization for Standardization) model of nursing actions and diagnosis while the CCC contains a collection of nursing interventions and outcomes which can be incorporated into the EHR. The benefit is increased interoperability between nursing terminologies.
There still is a large element of critical thinking required for use of standard terminology by nursing. Knowledge systems do not exist that link nursing point-of-care measures to nursing diagnoses, interventions or outcomes. The linkages would have to be empirically derived for automation and implementation within systems. This will require research and the development of an information model for nursing (supported by coded terminology).
So to answer the question posed at the beginning of this blog post, it’s clear that no “one” terminology meets the intricacy of nursing documentation. Gaps within standard terminologies result in the use of multiple terminologies within the EHR in order to obtain complete nursing documentation. Collecting and connecting data elements associated with the nursing process requires a more complete terminology than what is currently available. The nurse informaticist should place emphasis and resources on utilizing the appropriate terminology for valid and valuable data capture rather than picking one standard terminology.
Susan Matney is a Medical Informaticist with 3M Health Information Systems.
1The ONC has proposed Logical Observations Identifiers Names and Codes (LOINC) for laboratory and assessment measure, and has designated Systemized Nomenclature of Medicine Clinical terms (SNOMED CT) or ICD-9 CM for problem lists in Stage 1 of Meaningful Use. The proposed rule solely designates SNOMED CT for problem lists in Stage 2.