18 pages-Single-spaced-Class Journal

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IS531_Lecture-5.ppt

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Lecture 5

Standardized Terminology and Language in Health Care

(Chapter 15)

Learning Objectives

Standardized healthcare terminology and its importance

Languages and Classifications : Billing, Clinical, Nursing

Terminology structures: Classification System vs. Reference Terminology

Benefits of using structured terminologies within electronic healthcare records.

Issues and concerns

IS 531 : Lecture 5

Standardized Terminology

Also called “Controlled Terminology”

Structured and controlled languages developed and approved by an authoritative body

Healthcare terminology standards designed to enable and support interoperability and information sharing

Essential to the widespread implementation of EHRs

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Healthcare Terminology Standards

To represent, communicate, exchange, manage and report data information, and knowledge in healthcare

Ensure accurate, valid data collection among various providers and care settings

Meaningful Use: exchange clinical structured data in an accurate and complete manner to improve cost-efficiency in client care

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Terminology Definitions . . .

Concept: an expression with a single unambiguous meaning

Code: letters/characters/both to represent a concept

Codified concepts

Clinical terminology: describe health conditions and healthcare activities

Ontology: concepts are organized by their meaning describe a definitional structure-relationship

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. . .Terminology Definitions

Reference Terminology: a set of concepts with definitional relationship

To retrieve data across healthcare settings, domains, and specialties

Point-of-care Terminology (interface terminology): reference terminology in familiar term to clinicians

to support the entry of patient-related information into a computer program

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Types of Healthcare Terminologies

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Technology Development Guidelines

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Terminology and Nursing

Different terms indicate the same thing !

Need a standardized nursing language to describe care across clinical settings and specialists

How to document nursing problems, interventions, and outcomes

To support interoperability, sharing comparable data with other healthcare organizations

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Languages and Classifications . . .

Billing Codes
Mandated by Health Insurance Portability and Accountability Act (HIPAA)
International Classification of Disease (ICD) by World Health Organization (WHO):
for diagnosis reimbursement
Current Procedural Terminology (CPT) American Medical Association(AMA):
for billing and reimbursement of outpatient procedures and interventions

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ICD Examples

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CPT Examples

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Languages and Classifications . . .

Clinical Terminologies
Unified Medical Language Systems (UMLS) by National Library of Medicines (NLM), recognized by American Nurses Association (ANA)
Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT)
Logical Observation Identifiers, Name, and Codes (LOINC)

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SNOMED-CT

Globally recognized terminology (concepts, descriptions, and relationships)
Recognized by ANA
Promotes evidence-based practice
Undergoes review process to keep up to date
SNOMED-CT consists of 19 top-level hierarchies (Cf. p.305)
Using parent-child relationship to build vertical hierarchies

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SNOMED-CT Example

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LOINC

“Logical Observation Identifiers, Names, and Codes”
Terminologies for laboratory and clinical observations
For recording a single observation, measurement, test result.

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LOINC Examples

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Languages and Classifications . . .

Nursing Terminologies
Clinical Care Classification (CCC)
International Classification of Nursing Practice (ICN)
North American Nursing Diagnosis Association International (NANDA-I)
Nursing Intervention Classification (NIC)
Nursing Outcome Classification (NOC)
Omaha System
Perioperative Nursing Data Set (PNDS)

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Clinical Care Classification (CCC) System

To facilitate patient care documentation at the point of care
CCC of nursing diagnosis and outcome:
182 diagnosis concepts in categories and sub-categories; 3 outcome qualifiers.
CCC for nursing intervention:
198 concepts in categories and sub-categories to represent interventions, procedures, treatments, and activities.

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International Classification of Nursing Practice (ICNP)

For point-of-care and reference terminology
Contains diagnoses, actions, and outcomes in 7 axes (dimensions)

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ICNP Examples

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NANDA-I

“North American Nursing Diagnosis International”
Each nursing diagnosis actual or potential health problem has: description, definition, defining characteristics (manifestations, signs, symptoms)
13 domains , 7 axes(dimensions)

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NANDA Domains

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NANDA-I Examples

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Nursing Interventions Classification (NIC)

Describe interventions used in nursing care
30 classes, 7 domains and 542 interventions

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NIC Domains

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Nursing Outcomes Classification (NOC)

Describe outcomes related to nursing interventions
31 classes and 7 domains of outcomes
Each outcome has: definition, measurement scale, associated indicators, supporting references

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NOC Domains

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Omaha System

Research-based taxonomy for integrating and sharing clinical data
Assessment component—Problem Classification Scheme
Intervention component—Intervention Scheme
Outcomes component—Problem Rating Scale for Outcomes

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Omaha Systems

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Perioperative Nursing Data (PNDS) Set

Provide wording and definitions for nursing diagnoses, interventions, and outcomes
Allow collection data in a uniform way for analyses
4 components, 75 diagnoses, 135 interventions, and 27 nurse-sensitive patient care outcomes

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PNDS Example

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Benefits of Implementation

Client-specific benefits
Decreased costs
Increased quality
Improved outcomes
Improved safety

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Benefits of Implementation

Provider/Nursing Benefits
Complete access to data
Increased efficiency
Increased accuracy
Increased effectiveness
Improvement in client care

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Benefits of Implementation

Organizational Benefits
Decreased costs
Decision support
Outcome measurement
Data mining

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Issues and Concerns

Integrate systems with locally defined concepts, not using standard terminology

Select which terminology(ies) to use

Point-of-care terms and synonyms for clinical tasks must be locally developed: potential problems for other local systems

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Nursing Assessment Examples

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Nursing Diagnosis/Problem Examples

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Nursing Intervention Examples

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Nursing Goal/Potential Outcome Examples

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