Challenges and issues related to implementation of nursing vocabularies in computer-based systems

Evaluation of the expressiveness of an ICNP-based nursing data dictionary in a computerized nursing record system

This study evaluated the domain completeness and expressiveness issues of the International Classification for Nursing Practice-based (ICNP) nursing data dictionary (NDD) through its application in an enterprise electronic medical record (EMR) system as a standard vocabulary at a single tertiary hospital in Korea. Data from 2,262 inpatients obtained over a period of 9 weeks (May to July 2003) were extracted from the EMR system for analysis. Among the 530,218 data-input events, 401,190 (75.7%) were entered from the NDD, 20,550 (3.9%) used only free text, and 108,478 (20.4%) used a combination of coded data and free text. A content analysis of the free-text events showed that 80.3% of the expressions could be found in the NDD, whereas 10.9% were context-specific expressions such as direct quotations of patient complaints and responses, and references to the care plan or orders of physicians. A total of 7.8% of the expressions was used for a supplementary purpose such as adding a conjunction or end verb to make an expression appear as natural language. Only 1.0% of the expressions were identified as not being covered by the NDD. This evaluation study demonstrates that the ICNP-based NDD has sufficient power to cover most of the expressions used in a clinical nursing setting.

Electronic nursing documentation in primary health care

The aim of this study was to describe and analyse nursing documentation based on an electronic patient record (EPR) system in primary health care (PHC) with emphasis on the nurses' opinions and what, according to the nursing process and the use of the keywords, the nurses documented. The study was performed in one county council in the south of Sweden and included 42 Primary Health Care Centres (PHCC). It consisted of a survey, an audit of nursing records with the Cat-ch-Ing instrument and calculation of frequencies of keywords used during a 1-year period. For the survey, district nurses received a postal questionnaire. The results from the survey indicated an overall positive tendency concerning the district nurses' opinions on documentation. Lack of in-service training in nursing documentation was noted and requested from the district nurses. All three parts of the study showed that the keywords nursing interventions and status were frequently used while nursing diagnosis and goal were infrequent. From the audit, it was noted that medical status and interventions appeared more often than nursing status. The study demonstrated limitations in the nursing documentation that inhibited the possibility of using it to evaluate the care given. In order to develop the nursing documentation, there is a need for support and education to strengthen the district nurses' professional identity. Involvement from the heads of the PHCC and the manufactures of the EPR system is necessary, in cooperation with the district nurses, to render the nursing documentation suitable for future use in the evaluation and development of care.

Evaluation of the draft international standard for a reference terminology model for nursing actions

PURPOSE

The purpose of this study was to evaluate the draft ISO reference terminology model (RTM) for nursing actions. Nursing RTM models attempt to include concepts that are universally represented in nursing documentation to improve the depiction of nursing practice in computerized systems.

METHOD

Content analysis was used to decompose interventions into words and phrases, which were then mapped to the six model categories used to represent nursing actions in the draft ISO RTM. The decomposition of interventions was applied to nurses' documentation of pain interventions entered into a clinical information system.

FINDINGS

Consistent with the ISO standard requirements, all (100.00%) of the interventions contained an <action> word or phrase and a <<target>>. Additional findings are discussed in relation to earlier studies of terminology models.

CONCLUSIONS

It is recommended that terminology and information system developers consider this model in their ongoing system development, evaluation, maintenance, and revisions. Further evaluation of the ISO RTM for nursing will contribute to the goals of this specific model and the harmonization and integration with other health care models.

Collaborative efforts for representing nursing concepts in computer-based systems: international perspectives

Current nursing terminology efforts have converged toward meeting the demand for a reference terminology for nursing concepts by building on the foundation of existing interface and administrative terminologies and by collaborating with terminology efforts across the spectrum of health care. In this article, the authors illustrate how collaboration is promoting convergence toward a reference terminology for nursing by briefly summarizing a wide range of exemplary activities. These include: 1) the International Classification of Nursing Practice (ICNP) activities of the International Council of Nurses (ICN), 2) work in Brazil and Korea that has contributed to, and been stimulated by, ICNP developments, 3) efforts in the United States to improve understanding of the different types of terminologies needed in nursing and to promote harmonization and linking among them, and 4) current nursing participation in major multi-disciplinary standards initiatives. Although early nursing terminology work occurred primarily in isolation and resulted in some duplicative efforts, the activities summarized in this article demonstrate a tremendous level of collaboration and convergence not only in the discipline of nursing but in multi-disciplinary standards initiatives. These efforts are an important prerequisite for ensuring that nursing concepts are represented in computer-based systems in a manner that facilitates multi-purpose use at local, national, regional, and international levels.

Computer-based patient record systems

OBJECTIVES

To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care.

DATA SOURCES

Published articles, research studies, and review articles pertaining to CPR systems.

CONCLUSIONS

Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record.

IMPLICATIONS FOR NURSING PRACTICE

Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.

The evolution of a clinical database: from local to standardized clinical languages

For more than twenty years, the University of Iowa Hospitals and Clinics Nursing Informatics (UIHC NI) has been developing a clinical database to support patient care planning and documentation in the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System). Beginning in 1992, the database content was revised to standardize orders and to incorporate the Standardized Nursing Languages (SNLs) of the North American Nursing Diagnosis Association (NANDA), Nursing Diagnosis Extension Classification (NDEC), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). This paper reports the results of the database revision as well as recent usage data, new user selection methods for clinical content, and the advantages of a database utilizing SNLs.

The content coverage and organizational structure of terminologies: the example of postoperative pain

Concepts such as symptoms present specific representational challenges in the EMR. This is because concepts without clear boundaries and external referents such as physical objects can only be examined against other terminology-based concept representation systems. The truth and falsity of such concept representation is therefore relative to the terminology-based systems. Using the concept of acute postoperative pain as an example, we examined three terminology based approaches to representing the concept. Widely varying coverage across existing clinical terminologies was evident, although the common clinical approach to reporting attributes of symptoms provided a useful organizational structure and should be examined in relation to developing terminology and information models.

Representing nursing activities within a concept-oriented terminological system: evaluation of a type definition

OBJECTIVE

A type definition, as a component of the categorical structures of a concept-oriented terminology, must support nonambiguous concept representations and, consequently, comparisons of data that are represented using different terminologies. The purpose of the study was to evaluate the adequacy and utility of a proposed type definition for nursing activity concepts.

DESIGN

Nursing activity terms (n = 1039) from patient charts and intervention terms from two nursing terminologies (Home Health Care Classification and Omaha System) were decomposed into the attributes of the proposed type definition-Delivery Mode, Activity Focus, and Recipient.

MEASUREMENTS

Attributes of the type definition were coded as present or absent for each term by multiple raters. In addition, Delivery Mode was rated as Explicit or Implicit and Recipient was rated as Explicit, Implicit, or Ambiguous. The data were summarized using descriptive statistics. Inter-rater reliabilities were calculated for each attribute of the type definition.

RESULTS

All attributes of the type definition were present in 73.9 percent of the chart terms, 91.3 percent of Home Health Care Classification intervention terms, and 63.5 percent of Omaha System intervention terms. While Delivery Mode and Activity Focus were almost universally present, Recipient was problematic. It was rated as ambiguous in 4.8 percent of the chart terms, 8.7 percent of Home Health Care Classification intervention terms, and 36.5 percent of Omaha System intervention terms.

CONCLUSIONS

The study findings supported the adequacy and utility of the type definition. Further research is needed to refine the type definition and its use for representing nursing activity concepts within a concept-oriented terminological system.

Representing nursing judgements in the electronic health record

The naming of nursing phenomena and representing the phenomena in a standardized manner suitable for encoding in computer-based systems is a challenge for the nursing profession at the national and the international level. Considerable progress has been made in the development of classification systems for nursing practice. The focus of this article is on language systems developed to represent nursing judgements in computer-based systems, in particular the electronic health record. A review of two current systems and their proposed revisions (North American Nursing Diagnosis Association, NANDA, Taxonomies I and II, and the International Classification for Nursing Practice, ICNP, Alpha and Beta versions), according to the features suggested by the Computer-based Patient Record Institute (CPRI) for classification systems appropriate for implementation in computer-based systems, suggests that the evolving versions extend the current versions in terms of sufficient granularity (depth and level of detail) and atomic and compositional character. However, it is not clear from the literature available to date whether the characteristics that are most closely related to definition of a formal terminology (i.e. clear and non-redundant representation of concepts, syntax and grammar for logical constructions of compositional terms, synonyms and language independence) will be part of the evolving vocabularies. Formal terminology models and related tools have the potential to complement, extend, and refine existing nursing classification systems.