CU9 Standardizing Healthcare Data and Terminologies in Nursing Informatics Practice

Data standards

as applied to healthcare include **methods, protocols, terminologies and specifications for the collection, exchange, storage and retrieval of information associated with the healthcare applications** including medical records, medications, radiological images, payment and reimbursement, medical devices, monitoring systems and administrative process.

Syntax

refers to **structure** of communication; the equivalent of rules in spelling and grammar

Semantics

convey the **meaning** of communication; the equivalent of dictionary and thesaurus

Data Exchange / Messaging Standards

* these allow **transactions to flow consistently** between systems or organizations because they contain instructions for format, data, elements, and structure
* EX: Common standards includes HL and for administrative data such as patient demographics or encounters; DICOM for radiology images and NCPDP for electronic prescriptions.

Terminology Standards

* these **vocabularies** provide specific codes for clinical concepts such as diseases, problem list, allergies, medications, and diagnoses that might have varying textual descriptions in a paper chart or a transcription
* EX: LOINC for lab results; SNOMED for clinical terms; and ICD for medical diagnoses.

Document Standards

* these indicate what **type of information** is included in a document and where it can be found.
* A common standard in paper medical records in the **SOAP (Subjective, Objective, Assessment, Plan) format****.**
* EX: CCR (Continuity of Care Record)

CCR (Continuity of Care Record)

provides a standard format for **inter-provider communication**, including patient identifying information, medical history, current medications, allergies, and a care plan recommendation.

Conceptual Standards

* these allow data to be transported across systems without **losing meaning and context**.
* EX: the HL7 RIM (Reference Information Model)

HL7 RIM (Reference Information Model)

provides a framework for **describing clinical data and the context surrounding it.**

Application Standards

* these determine the way business rules are **implemented and software systems interact****.**
* EX: including sign-on, which simultaneously logs a user into multiple applications within the same environment; and standards for providing a comprehensive way of viewing information across multiple, non-integrated database

Architecture Standards

* these define the process involving in data storage and distribution.
* EX: The Centers for Disease Control’s Public Health Information Networks/ National Electronic Disease Surveillance System
* An emerging functional architecture is the national electronic health record proposed by the Institute of Medicine and HL7, commissioned by the HHS.

Nursing Minimum Data Set (NMDS)

* current standardization effort
* American Nurses Association Steering Committee on Databases to Support Clinical Practice (ANASCD) is involve in developing this
* Described as “the minimum data elements necessary for defining the cost and quality of nursing care”

American Nurses Association (ANA)

* 1991
* created a committee to **review nursing languages and to recognize those that had met the committee’s own criteria as potentially useful to support nursing practice**
* since that time, criteria have evolved with the growing knowledge of terminology standards in health informatics

NANDA - (diagnoses from the North American Nursing Diagnosis Association)

While ICD-9-CM codes describe a disease or injury, describe a **patient's reactions to the disease and to treatment.**

NIC - (Nursing Interventions Classification)

* a **standardized language for treatments** that nurses perform.
* was developed at the University of Iowa and information is published by Mosby

NOC - (Nursing Outcomes Classification)

* Also developed at the University of Iowa.
* It goes beyond the work of NIC toward **classification of outcomes useful in clinical nursing**

Omaha System

* developed by the **Omaha Visiting Nurse Association.**
* It covers some of the same ground as the NANDA nursing diagnoses, and incorporates the Nursing Minimum Data Set (NMDS).

Saba’s Home Healthcare; the Home Health Care Classification of Nursing Diagnoses and Interventions (HHCC)

* developed at Georgetown University


* focuses on community health

UMLS Metathesaurus; The National Library of Medicine UMLS Metathesaurus

includes terms from NANDA, NIC, NOC, HHCC, and others.

Clinical Care Classification (CCC) System

* a standardized, coded nursing terminology that identifies the discrete elements of nursing practice
* provides a unique framework and coding structure for capturing the essence of patient care in all health care settings.

Perioperative Nursing Data Set (PNDS)

Describes perioperative nursing practice with a sub-set of terms that specifically describe __perioperative nursing diagnoses, nursing interventions, and patient outcomes in surgical settings from pre-admission until discharge.__

SNOMED CT; (Systematized Nomenclature of Medicine-Clinical Terms)

considered to be the most comprehensive, multilingual clinical healthcare terminology in the world.

PCDS; The Patient Care Data Set (version 4.0, 1998)

* contains a data dictionary and sets of terms and codes representing specific values of Patient Problems (363 terms), Patient Care Goals (311 terms), and Patient Care Orders (1357 terms).
* It was recognized in 1998 by the American Nurses Association (ANA) as one of the vocabularies to be considered for use by nurses, and is included in the National Library of Medicine's Metathesaurus.

International Classification for Nursing Practice ICNP

a combinatorial terminology for nursing practice developed by the international nursing community under the sponsorship of the International Council of Nurses (ICN).

Nursing Management Minimum Data Set

Data variables categorized into environment, nurse resources, and financial resources that are needed to inform the decision making process of nurse executives related to leading and managing nursing services delivery and care coordination.

health informatics literature

provides an evolving framework that enumerates the criteria that render healthcare terminologies suitable for implementation in computer-based systems

Concept

**thought or reference**; unit of knowledge created by a unique combination of characteristics (an abstraction of a property of an object or of a set of objects.)

Objects

the referent; anything perceivable or conceivable.

Term

the symbol; verbal designation of a general concept corresponds to two or more objects which form a group by reason of common properties.

Terminology Model

* concept-based representation of domain-specific terms that is optimized for the management of terminology definitions.
* It encompasses:
* Schemata
* Type Definitions

Schemata

* incorporate **domain-specific knowledge about the typical constellation of entities, attributes and events in the real world and reflect plausible combinations of concepts.**
* EX: “pain” can be combined with “acute” to make “acute pain”

Type Definitions

* are obligatory conditions that state only the essential properties of the concept.
* EX: a nursing activity must have a recipient, an action and a target.

Representation Language

terminology models may be **formulated and elucidated in an ontology language**

Ontology language

* represents **classes and their properties**.
* able to support, though explicit semantics, the formal definition of concepts in terms of their relationships with another concept

Computer-Based Tools

a representation language may be implemented using **description logic within a software system or by a suite of software tools.**