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THEOFFICEOFTHENATIONALCOORDINATORFORHEALTHINFORMATIONTECHNOLOGY.pdf

Standard Nursing Terminologies: A Landscape Analysis

MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726

May 15, 2017

Identifying Challenges and Opportunities within Standard Nursing Terminologies 2

Table of Contents

I. Introduction ....................................................................................................... 4

II. Background ........................................................................................................ 4

III. Landscape Analysis Approach ............................................................................. 6

IV. Summary of Background Data ............................................................................ 7

V. Findings.............................................................................................................. 8 A. Reference Terminologies .....................................................................................................8

1. SNOMED CT ................................................................................................................................... 8

2. Logical Observation Identifiers Names and Codes (LOINC) ........................................................ 10

B. Interface Terminologies .................................................................................................... 11

1. Clinical Care Classification (CCC) System .................................................................................... 11

2. International Classification for Nursing Practice (ICNP) ............................................................. 12

3. NANDA International (NANDA-I) ................................................................................................. 14

4.

5. Omaha System ............................................................................................................................ 16

6. Perioperative Nursing Data Set (PNDS) ...................................................................................... 18

7. Alternative Billing Concepts (ABC) Codes ................................................................................... 19

C. Minimum Data Sets .......................................................................................................... 20

1. Nursing Minimum Data Set (NMDS) ........................................................................................... 20

2. Nursing Management Minimum Data Set (NMMDS) ................................................................. 22

VI. Health IT Developers - Perspective ................................................................... 23

VII. Emerging Issues in Using SNTs .......................................................................... 24 1. Lack of Alignment on Terminology Standards for Nursing Content Definition .......................... 24

2. Customized Development and Implementation of EHR Systems ............................................... 24

3. Resource-Intensive Mapping Requirements, Curation and Maintenance ................................. 24

4. Licensing Fees, Copyrights and Associated Pricing Challenges ................................................... 25

5. Incomplete Electronic Documentation of Nursing Care ............................................................. 25

4. Nursing Interventions Classification System (NIC) and Nursing Outcomes Classification (NOC) .................................................................................................................... 15

Identifying Challenges and Opportunities within Standard Nursing Terminologies 3

VIII. Conclusion ....................................................................................................... 26

Appendix A: Expanded Nursing Terminologies Timeline ............................................. 27

Appendix B: Pre-Determined Landscape Assessment Questionnaire .......................... 34

Appendix C: EHR Developer Assessment Questionnaire ............................................. 35

Appendix D: List of Abbreviations .............................................................................. 36

References ................................................................................................................. 38

Identifying Challenges and Opportunities within Standard Nursing Terminologies 4

I. Introduction

With the rapid adoption of health IT and the promotion of interoperability to improve health, consistent standards and common data elements are the foundation for the advancement of care models. This advancement is based on objectives such as capturing sharable patient and care information across disciplines and care settings, enabling more accurate and less burdensome measurement of the quality of care delivered, and supporting ongoing research and analysis. Within this context, the nursing profession can contribute an enormous amount of valuable data related to the care of the patient and the nursing process. However, if nursing data are not stored in a standardized electronic format, or easily translated to a vocabulary used by interdisciplinary care team members, the value and contributions of nursing to patient outcomes may not be measurable or retrievable (Welton & Harper, Measuring Nursing Care Value, 2016). With more than 3.6 million members, nurses constitute the largest workforce in health care, and hospital-based nurses spend as much as 50 percent of their time in direct patient care (Hurst) (Nursing Fact Sheet, 2011) (McMenamin, 2016). As we move forward with innovative strategies to optimize the health of patients and communities, the omission of nursing data due to a lack of agreement on a standardization strategy would be unfortunate.

To this end, the Office of the National Coordinator for Health IT (ONC) is working with MBL Technologies and Clinovations Government + Health, Inc. (Clinovations GovHealth) (hereafter the project team) to conduct a landscape assessment to better understand the current state and challenges associated with using terminologies and classifications to support nursing practice within health information technology (health IT) solutions. Through a literature review and interviews with terminology owners, this assessment examines the current state of development and usage within the 12 Standard Nursing Terminologies (SNT) recognized by the American Nurses Association (ANA).

This report:

 Defines a brief history of the development of standard nursing terminologies and efforts to gain consensus on a strategy for their use;

 Includes the level of advancement and interoperability of individual terminologies with electronic health records (EHRs); and

 Identifies themes in the form of challenges and opportunities.

II. Background

Nursing terminologies and vocabulary structures first developed in 1973, and many have changed significantly since their inceptions. Realizing that the standardization of nursing care documentation was a critical component to support interoperable health information, the ANA in 1989 created a process to recognize languages, vocabularies and terminologies that support the nursing practice (ANA, 2015). Current action plans and guidelines, descending from the work of individuals such as James J. Cimino and organizations such as the National Committee on Vital and Health Statistics (NCVHS) and the ANA, continue to be refined (Cimino J. , 1998) (Cimino, Hripcsak, Johnson, & Clayton, 1989) (Sujansky, 2002). However, the inability to ensure the availability of sharable and comparable nursing data remains an issue. Increased focus on longitudinal and interdisciplinary documentation, care quality and value

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precipitates a need to accurately quantify the contribution of each care team member for optimization of care workflows across settings. Further, high-quality nursing data can assist in the optimal integration of registered nurses into high-value, lower-cost approaches to longitudinal care (Welton & Harper, Measuring Nursing Care Value, 2016). Figure 1 below provides a high-level timeline of significant events that have occurred in the evolution and development of SNTs. A detailed and expanded events timeline is in Appendix A.

Figure 1. Consolidated SNT timeline

Currently, the ANA recognizes two minimum data sets, two reference terminologies and eight interface terminologies for facilitating documentation of nursing care and interoperability of nursing data between multiple concepts and nomenclatures within IT systems (ANA, ANA Recognized Terminologies that Support Nursing Practice, 2012). The definitions of each of these types of terminologies are as follows:

 Minimum data sets are “…a minimum, essential set of data elements with standardized definitions and codes collected for a specific purpose, such as describing clinical nursing practice or nursing management contextual data that influence care” (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record, 2008).

 Interface terminologies (point-of-care) include the actual terms/concepts used by nurses for describing and documenting the care of patients (individuals, families and communities) (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record, 2008).

 Reference Terminologies are designed to “…provide common semantics for diverse implementations” (CIMI, 2013) and ideally, they enable clinicians to use terms appropriate for their discipline-specific practices, then map those terms through a reference terminology to

Identifying Challenges and Opportunities within Standard Nursing Terminologies 6

communicate similar meaning across systems (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008).

Table 1 below includes the 12 SNTs by category.

Table 1. ANA-Recognized Standard Nursing Terminologies

Interface Terminologies Minimum Data Sets 1. Clinical Care Classification (CCC) System 2. International Classification for Nursing

Practice (ICNP) 3. North American Nursing Diagnosis

Association International (NANDA-I) 4. Nursing Interventions Classification System

(NIC) 5. Nursing Outcomes Classification (NOC) 6. Omaha System 7. Perioperative Nursing Data Set (PNDS) 8. ABC Codes

1. Nursing Minimum Data Set (NMDS) 2. Nursing Management Minimum Data

Set (NMMDS)

Reference Terminologies 1. Logical Observation Identifiers Names

and Codes (LOINC) 2. SNOMED Clinical Terms (SNOMED CT)

III. Landscape Analysis Approach

The project team first performed an internet search to obtain background on standard nursing terminologies. Using information gathered in the search and focusing specifically on ANA-recognized SNTs, the project team proposed a list of interview contacts within each ONC-validated SNT organization. Interviews were conducted using an interview guide (Appendix B). For accuracy purposes, the project team used standardized definitions for the variables of current usage, existing interoperability and major barriers or issues to implementing and using SNT. Data on the following topics was collected for analysis:

 SNT goals and objectives for the terminology ;  Terminology versioning and release schedules;  Latest version of SNT as well as update timing and methodology;  Current usage and activities;  Maintenance and sustainability issues;  Level of interoperability with electronic health records;  Major issues or barriers associated with integration and implementation; and  The future state of the SNT.

Discussions touched on each SNT’s perceived or actual barriers to interoperability, how easily an SNT is implemented within an EHR, and the typical process for that implementation. Details of those interviews are in Section IV: Summary of Background Data, below.

After completion of interviews with terminology representatives, the project team approached three electronic health record developers to provided background on how SNTs are implemented and used in hospital and ambulatory health information technology applications. Although these interviews were

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unstructured, the project team developed a framework for guiding the discussion (Appendix C). Developer interviews were collated and overarching perspectives were identified for further discussion in Section VI: Health IT Developers - Perspectives. When all data collection was complete, the project team evaluated the information to identify gaps, similarities, barriers, challenges and opportunities related to the current status and use of SNTs. This information is in Section VII: Emerging Issues in Using SNTs.

IV. Summary of Background Data

The table below summarizes the background data collected during the landscape analysis.

Table 2. Summary of Background Data

Terminology Latest Update via

UMLS Original

Publication Date Publication Schedule SNOMED Clinical Terms (SNOMED CT)

2017 SNOMED (1975) SNOMED II (1979) SNOMED CT (2002)

Twice annually: January and July.

Logical Observation Identifiers Names and Codes (LOINC)

2017 1994 Twice annually: December and June.

Alternative Billing Concepts (ABC) Codes

2009 2000 Schedule based on availability of resources.

Clinical Care Classification (CCC) System

2012 1991 CCC System National Scientific Advisory Board meets annually.

International Classification for Nursing Practice (ICNP)

2015 Alpha v. (1996) Released in May or June of the second year.

NANDA International (NANDA-I)

2002 1973 Every three years.

Nursing Interventions Classification System (NIC)

2008 1992 Every five years.

Nursing Outcomes Classification (NOC)

2008 1997 Every five years.

Omaha System 2005 1975 Reviewed every two years. Perioperative Nursing Data Set (PNDS)

2011 1999 Every five years.

Nursing Minimum Data Set (NMDS)

NMDS is not in UMLS.

1983 No

Nursing Management Minimum Data Set (NMMDS)

NMMDS is not in UMLS. However, it is fully encoded with LOINC, which is in UMLS.

1996/1997 No

Identifying Challenges and Opportunities within Standard Nursing Terminologies 8

V. Findings

A. Reference Terminologies Reference terminologies are designed to “…provide common semantics for diverse implementations” (CIMI, 2013) and ideally, they enable clinicians to use terms (synonyms) appropriate for their discipline-specific practices (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008) (Westra, et al., 2015). The mapping of interface terminologies to reference terminologies allows a standard, shared vocabulary to communicate data across settings.

The ANA-recognized reference terminologies are SNOMED CT and LOINC (characterized by the ANA as “multidisciplinary” terminologies). The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) require the use of a reference terminology (SNOMED CT and LOINC) for Meaningful Use incentive payments and for certification, respectively.

1. SNOMED CT SNOMED CT

Latest Update via UMLS 2017 Original Publications SNOMED (1975)

SNOMED II (1979) SNOMED CT (2002)

Owned and distributed by SNOMED International, SNOMED CT is a comprehensive, multilingual clinical health care terminology used in more than 50 countries. When implemented into health IT, SNOMED CT provides a multidisciplinary approach to consistently and reliably represent clinical content in EHRs and other health IT solutions. SNOMED CT is important in health IT development and implementation as it supports the development of high-quality clinical content and provides a standardized way to record clinical data that enables meaning-based retrieval and exchange (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008).

SNOMED CT content is represented using three different types of components, including concepts representing clinical meaning; descriptions that link terms to concepts; and relationships to link each concept to other related concepts. It is augmented by reference sets that support customization and enhancement of SNOMED CT, including subsets, language preferences and mapping from or to other terminologies. SNOMED CT maps provide explicit links to other health-related classifications and coding systems, e.g., to International Classification of Diseases (ICD-10).

The U.S. Edition of SNOMED CT is the official source of SNOMED CT for use in the United States and is a standalone release that combines content of both the U.S. extension and the International release of SNOMED CT. For example, the U.S. Edition of SNOMED CT contains subsets representing Clinical Observations Recordings and Encoding (CORE) Problem list subset, as well as a Nursing Problem List subset to facilitate use of SNOMED CT as the primary coding terminology.

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Process for Updating/Publishing Standard SNOMED International provides its members with the ability to request changes to SNOMED CT through National Release Centers (NRC) in member countries. In some cases, changes may only be implemented in a national extension. If the change has international relevance, it is forwarded to SNOMED International for consideration of inclusion in the next release cycle. A new version of SNOMED CT is released to SNOMED International members in July and in January yearly. As the U.S. member of SNOMED International, NLM distributes SNOMED CT at no cost through the Uniform Medical Language System (ULMS) Metathesaurus via a licensing program.

Usage/Activity SNOMED CT is required in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Detailed information on each edition’s specific SNOMED CT criterion requirements are in the respective regulations and referenced in the “Standards Hub” on ONC’s website: https://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub

Challenges Before SNOMED International purchased SNOMED CT from the College of American Pathologists (CAP), many ANA-recognized interface terminologies for nursing were integrated into SNOMED CT through the mapping of the nursing terms to valid concepts within SNOMED CT. However, SNOMED International did not purchase these maps from CAP, so they are not included in the international version of SNOMED CT. In addition, the NLM does not maintain mappings in the U.S. Edition as new editions are released. Therefore, any existing maps from nursing-specific terminologies to SNOMED CT would be maintained by each SNT.

Opportunities SNOMED CT has a broad scope of coverage, including concepts across a wide range of multidisciplinary clinical information while maintaining the relationships between the concepts and supporting important capabilities such as clinical decision support, quality measurement and research initiatives. With greater inclusion of nursing content, SNOMED CT could be utilized at the user interface, eliminating the need for mapping and integration with other interface terminologies.

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2. Logical Observation Identifiers Names and Codes (LOINC) LOINC

Latest Update via UMLS 2017 Original Publication 1994

The Regenstrief Institute maintains LOINC as a comprehensive clinical terminology for identifying tests, measurements and observations. LOINC includes terms for laboratory test orders and results, clinical measures such as vital signs, standardized survey instruments and other patient observations. Comprised of more than 71,000 observation terms that primarily represent laboratory and clinical observations, it is available at no cost, and it is used extensively within U.S. health IT systems for the exchange of clinical information.

In 1999, it was identified by the Health Level Seven (HL7) Standards Development Organization (SDO) as the preferred code set for laboratory test names in transactions between health care facilities, laboratories, laboratory testing devices and public health authorities (Logical Observation Identifiers Names and Codes (LOINC), 2015). LOINC’s initial purpose was to develop a common terminology for laboratory and clinical observations that could be used in HL7 messages. However, it has been expanded to other areas, including additional clinical observations such as nursing assessment questions. In 2002, the Clinical LOINC Nursing Subcommittee was developed to provide LOINC codes for observations at key stages of the nursing process, including assessments, goals and outcomes, as well as administrative and regulatory data related to nursing care (Nursing Resources for Standards and Interoperability, 2015).

Along with SNOMED CT, LOINC is multidisciplinary. It is available in several file formats for ease of implementation (Regenstrief and the SNOMED International are working together to link LOINC and SNOMED CT., 2013). As part of a cooperative agreement between the Regenstrief Institute and SNOMED International, guidance on the use of SNOMED CT and LOINC together is published with LOINC-SNOMED CT Mappings and Expression Associations to provide a common framework for the use of LOINC with SNOMED CT (Vreeman, 2016).

Process for Updating/Publishing Standard LOINC updates are published every June and December. As a companion to LOINC, the Regenstrief Institute publishes a software tool called Regenstrief LOINC Mapping Assistant (RELMA) to search terminology, assist in the mapping of LOINC to local codes and suggest updates to the LOINC terminology.

Usage/Activity It is estimated that LOINC has more than 44,000 registered account users. LOINC is interoperable with most EHR developer products. When purchased, the user agrees to LOINC’s “Terms of Use” which binds the user and gives notice of LOINC copyright and licensing policy. In the current policy, LOINC permits “in perpetuity, without payment of license fees or royalties, to use, copy or distribute” licensed materials “for any commercial or non-commercial purpose” (Copyright Notice and License). LOINC is a required vocabulary in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Detailed information on each edition’s specific LOINC criterion requirements is in the respective regulations and is referenced in the “Standards Hub” on ONC’s website, here: https:// www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub.

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Challenges Because no license is required, it is hard to track specific usage of LOINC. In addition, there is no formal mechanism to monitor the use of LOINC to ensure consistent use and accurate mapping, although the “Terms of Use” state that the “users shall not use any of the Licensed Materials for the purpose of developing or promulgating a different standard for identifying patient observations, such as laboratory test results” (Copyright Notice and License).

Opportunities The study done by Matney to align a minimum set of nursing assessment data with LOINC and SNOMED CT provides a framework for a systematic approach for the standardized representation of nursing assessments (Matney, et al., 2016).

B. Interface Terminologies Interface terminologies are defined as “a systematic collection of health care-related terms that supports clinicians’ entry of patient-related information into computer systems” (Rosenbloom, Miller, Johnson, Brown, & Ekin, 2006). Seven recognized terminologies in this category were designed specifically for use in nursing, but some have evolved to include other disciplines. In addition, ABC Codes are included in this category, although the ANA recognition process originally grouped ABC Codes as a “multidisciplinary” terminology.

1. Clinical Care Classification (CCC) System CCC System

Latest Update via UMLS 2012 Original Publication 1991

A 1991 research project conducted by Dr. Virginia Saba and colleagues from Georgetown University resulted in the development of the Home Health Care Classification System (HHCC), which evolved into the Clinical Care Classification (CCC) System (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). The research focused on creating a process to identify and classify patients to determine resources and measures for outcomes of care. The result was the original version of CCC of Nursing Diagnoses and CCC of Nursing Interventions terminologies that were classified by 20 care components, ultimately establishing a standard framework for assessing, documenting and evaluating nursing care (Saba V. , Nursing Classifications: Home Health Care Classification System (HHCC): An Overview., 2002). SabaCare Incorporated currently maintains the nursing terminology. The codes are structured within an implicit information model to link nursing diagnoses to interventions and outcomes. There is no license fee for using CCC.

Process for Updating/Publishing Standard The National CCC Advisory Scientific Board, part of SabaCare Incorporated, meets annually to review all submitted concepts, terms or labels for consideration. However, the terminology is not regularly published. Recommendations regarding development of new versions are made only after the Advisory Board has evaluated new ideas. CCC is considering the release of a Plan of Care (PoC) and a Workload Actions Measures Method for new users in the future.

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Usage/Activity Dr. Saba states that the CCC System can be used in all clinical settings for documenting nursing practice. Such settings include point-of-care nursing documentation, nursing education, nursing research and nursing administration. The CCC System is being implemented into EHR systems in three different methods (Saba V. , Clinical Care Classification System Version 2.5 User's Guide, 2012):

 Health care facilities obtain CCC System permission to integrate the CCC concepts into the respective facility’s data dictionary. The health care facility uses the CCC System to develop and code its plan of care.

 An EHR developer obtains CCC System permission and uses the CCC System to develop a proprietary standardized set of care plans, which is marketed commercially to health care facilities.

 An EHR developer obtains CCC System permission and inputs the CCC System’s concepts into its proprietary data dictionaries for use by customers to adapt and develop care plans.

Challenges

Opportunities CCC System is used by a variety of U.S. health systems. There is no licensing fee with CCC, so health systems can use the terminology without incurring that type of expense. The CCC is free for download from: http://www.clinicalcareclassification.com.

2. International Classification for Nursing Practice (ICNP) ICNP

Latest Update via UMLS 2015 Original Publications Alpha version (1996)

Beta version (1999)

None identified.

ICNP is an international terminology that provides description and comparison for nursing practice and allows for cross-mapping between other terminologies. The classification includes nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions. Specifically, ICNP describes nursing care of people in a variety of settings and enables comparison of nursing data across clinical populations, settings and geographical areas and time ((ICN), n.d.). The International Council of Nurses (ICN) developed ICNP in 1990 (formalized in 2000) to be a unifying framework in which local language and existing nursing terminologies and classifications could be cross-mapped to support data interoperability. ICN owns and copyrights ICNP; permission for use is required. Commercial use involving distribution of a product for-profit (e.g. software products or publications) requires a small licensing fee; non-commercial use (e.g. research in education) is free (Coenen A. , 2003). Other uses, such as government use within a national health information system, are negotiated on a case-by-case basis. ICN anticipates discounted pricing for developing countries. Besides protection of copyright, ICN is most concerned about facilitating access to ICNP for use by nurses (Coenen A. , 2003).

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Process for Updating/Publishing Standard The alpha version released in 1996; the Beta version …