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

Nursing Classification and Terminology Systems

A number of terminologies exist that represent concepts of relevance to nurses, although none of these is in use by Australian nurses. Without consensus, nursing language and definitions incorporated in clinical information systems now being implemented will continue to vary considerably. The result will be an inability to compare nursing practice, or to aggregate data for research purposes, or to collect national statistical data to demonstrate the significance of nurses' contributions to health care. This article provides an international historical overview of nursing terminology developments relative to what is happening in Australia, brief reviews of the many available nursing terminologies, an update of this work relative to activities being undertaken towards the development and adoption of standards, and a discussion about desirable future research and development activities.

Nursing informatics: two foundational developments

Health informatics technologies exist to support the work of the health professionals. As successful healthcare outcomes increasingly rest on the active participation of patients and lay persons, these technologies must also directly support the important contributions of patients as they engage in self-help, self-care, and disease management activities. The unique role of nursing in the healthcare system is to attend to those aspects of the person that constitute the human response to disease and development, and to deliver interventions that help to compensate for, restore, or improve patients’ abilities to manage health status. This uniqueness is reflected in the terms used by nurses to characterize patient problems, which are operationally distinct from those used in medicine, and also in the nature of homecare technologies needed by nurses. Nurses provide an important but distinct contribution to patient care, and the informatics technologies needed to support nurses and their patients are complementary but distinctly different from those that support the medical aspect of care. Two developments in health informatics, formal languages and telehealth, serve as the core foundations of technological support for healthcare in the twenty-first century. Nurses contribute to and benefit from advances in language development and telehealth innovations.

The Role of Information Systems to Manage Cerebral Palsy

Objective In healthcare system, it is necessary to have exact and accurate information in order to address health care needs and requirements of society members as well as expectations of policy makers, planners and decision makers. The aim of this narrative review article was to explain the role of information systems in cerebral palsy management and identify the advantages and barriers to the development of cerebral palsy registry system. Data were collected using databases such as of Science Direct, PubMed, Proquest, Springer, and SID (Scientific Information Database). Overall, 65 sources were selected. One of the biggest challenges for children with physical and motor disabilities in rehabilitation center is access to a system, which provides a comprehensive data set reflecting all information on a patient's care. Thus, data and information management in children with physical and motor disability such as cerebral palsy facilitates access to data and cerebral palsy data comparison as well as the monitoring incidence rate of cerebral palsy, enhancing health care quality; however, there are always numerous barriers to establish the system. One of the ways to overcome these problems is the establishment of a standard framework of minimum data sets and exact definition of its data components. Reliable standards in the use of applications as well as user-friendly software will ensure patients' data extraction and registration.

Korean hospice nursing interventions using the Nursing Interventions Classification system: a comparison with the USA

In this study, nursing interventions used by hospice nurses in Korea were identified and compared with core interventions selected by US end-of-life care nurses in order to determine similarities and differences between the two nations regarding such care. Data were collected from the electronic medical records of 353 hospice patients admitted to a tertiary hospital in Korea over a period of two years. First, extracted narrative interventions were mapped onto the Nursing Interventions Classification for comparison with interventions selected by nurses in the USA. A total of 56,712 intervention statements were mapped onto 147 Nursing Interventions Classification interventions. Hospice nurses in Korea performed more nursing interventions in the physiological basic domain, compared to nurses in the USA. The most frequently-used interventions in Korea were related to patient pain management. Among 47 core Nursing Interventions Classification interventions used in the USA, only 18 were used by Korean nurses in this study. This study highlights cultural differences in hospice care nursing interventions between the two countries.

Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting

PURPOSE

This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology.

METHODS

An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review.

FINDINGS

Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans.

CONCLUSIONS AND IMPLICATIONS

The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care.

CLINICAL RELEVANCE

The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care.

What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

BACKGROUND

The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians.

OBJECTIVES

This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts.

DESIGN

Observational, longitudinal, multicentre study.

SETTING

A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included.

PARTICIPANTS

Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%).

METHODS

The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals.

RESULTS

Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking.

CONCLUSIONS

Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting.

Mapping the Diagnosis Axis of an Interface Terminology to the NANDA International Taxonomy

Background. Nursing terminologies are designed to support nursing practice but, as with any other clinical tool, they should be evaluated. Cross-mapping is a formal method for examining the validity of the existing controlled vocabularies. Objectives. The study aims to assess the inclusiveness and expressiveness of the nursing diagnosis axis of a newly implemented interface terminology by cross-mapping with the NANDA-I taxonomy. Design/Methods. The study applied a descriptive design, using a cross-sectional, bidirectional mapping strategy. The sample included 728 concepts from both vocabularies. Concept cross-mapping was carried out to identify one-to-one, negative, and hierarchical connections. The analysis was conducted using descriptive statistics. Results. Agreement of the raters' mapping achieved 97%. More than 60% of the nursing diagnosis concepts in the NANDA-I taxonomy were mapped to concepts in the diagnosis axis of the new interface terminology; 71.1% were reversely mapped. Conclusions. Main results for outcome measures suggest that the diagnosis axis of this interface terminology meets the validity criterion of cross-mapping when mapped from and to the NANDA-I taxonomy.

A framework for harmonizing terminologies to support representation of nursing practice in electronic records

Nursing terminology development efforts in the United States and globally provide concept coverage across many domains of nursing practice. Efforts to integrate concepts from across terminology systems into a single reference terminology support broad concept coverage but do not provide a means to leverage the full benefits of the individual terminology systems. The purpose of this paper is to explore the feasibility of harmonizing the 198 Clinical Care Classification (CCC) System core intervention concepts with intervention concepts in the International Classification for Nursing Practice (ICNP®) as a means to leverage both the information model components of the CCC system and the broad concept coverage of the ICNP®. Findings suggest that the CCC system and ICNP® are largely interoperable and a common framework underlying the two terminology systems provides a foundation for harmonization.

Implications for Nursing Research and Generation of Evidence

A sound informatics infrastructure is essential to optimise the application of evidence in nursing practice. A comprehensive review of the infrastructure and associated research methods is supported by an extensive resource of references to point the interested reader to further resources for more in depth study. Information and communication technology (ICT) has been recognized as a fundamental component of applying evidence to practice for several decades. Although the role of ICT in generating knowledge from practice was formally identified as a nursing informatics research priority in the early 1990s (NINR Priority Expert Panel on Nursing Informatics, 1993), it has received heightened interest recently. In this chapter, the authors summarize some important trends in research that motivate increased attention to practice-based generation of evidence. These include an increased emphasis on interdisciplinary, translational, and comparative effectiveness research; novel research designs; frameworks and models that inform generation of evidence from practice; and creation of data sets that include not only variables related to biological and genetic measures, but also social and behavioral variables. The chapter also includes an overview of the ICT infrastructure and informatics processes required to facilitate generation of evidence from practice and across research studies: (1) information structures (e.g., re-usable concept representations, tailored templates for data acquisition), (2) processes (e.g., data mining algorithms, natural language processing), and (3) technologies (e.g., data repositories, visualization tools that optimize cognitive support). In addition, the authors identify key knowledge gaps related to informatics support for nursing research and generation of evidence from practice.

The adequacy of ICNP version 1.0 as a representational model for electronic nursing assessment documentation

OBJECTIVES

The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice (1) (ICPN) Version 1.0 as a representational model for nursing assessment documentation.

DESIGN AND MEASUREMENTS

To identify representational requirements of nursing assessments, the authors mapped key concepts and semantic relations extracted from standardized and local nursing admission assessment documentation forms/templates and inpatient admission assessment records to the ICNP. Next, they expanded the list of ICNP semantic relations with those obtained from the admission assessment forms/templates. The expanded ICNP semantic relations were then validated against the semantic relations identified from an additional set of admission assessment records and a set of 300 randomly selected North American Nursing Diagnosis Association defining characteristic phrases. The concept coverage of the ICNP was evaluated by mapping the concepts extracted from these sources to the ICNP concepts. The UMLS Methathesaurus was then used to map concepts without exact matches to other American Nursing Association (ANA) recognized terminologies.

RESULTS

The authors found that along with the 30 existing ICNP semantic relations, an additional 17 are required for the ICNP to function as a representational model for nursing assessment documentation. Eight hundred and five unique assessment concepts were extracted from all sources. Forty-three percent of these unique assessment concepts had exact matches in the ICNP. An additional 20% had matches in the ICNP classified as narrower, broader, or "other." Of the concepts without exact matches in the ICNP, 81% had exact matches found in other ANA recognized terminologies.

CONCLUSIONS

The broad concept coverage and the logic-based structure of the ICNP make it a flexible and robust standard. The ICNP provides a framework from which to capture and reuse atomic level data to facilitate evidence-based practice.

Modeling the distribution of Nursing Effort using structured Labor and Delivery documentation

Our study objectives included the development and evaluation of models for representing the distribution of shared unit-wide nursing care resources among individual Labor and Delivery patients using quantified measurements of nursing care, referred to as Nursing Effort. The models were intended to enable discrimination between the amounts of care delivered to patient subsets defined by attributes such as patient acuity. For each of five proposed models, scores were generated using an analysis set of 686,402 computerized nurse-documented events associated with 1093 patients at three hospitals during January and February 2006. Significant differences were detected in Nursing Effort scores according to patient acuity, care facility, and in scores generated during shift change versus non-shift change hours. The development of nursing care quantification strategies proposed in this study supports outcomes analysis by establishing a foundation for measuring the effect of patient-level nursing care on individual patient outcomes.

What nurses do: use of the ISO Reference Terminology Model for Nursing Action as a framework for analyzing MICU nursing practice patterns

This study utilized the ISO RTM for Nursing Action as a model to decompose nursing actions and as a framework for analyzing the practice patterns of nurses working in a medical intensive care unit (MICU). Observations were made in a 25-bed MICU and nursing actions recorded in terms of model attributes. 1013 actions were observed; decomposed into the ISO RTM categories, they represented 68 distinct actions, 166 targets, 6 recipients of care, 81 means, 16 routes and 115 sites. The most frequent actions were 'assessing' (19.1%) and 'documenting' (10.5%). The most frequent target was 'medication' (8.5%) and the most frequent recipient of care was 'patient' (94.1%). Data revealed nurses perform, yet do not document all actions. Thus in this setting, the existing documentation system does not adequately represent all aspects of nursing practice. The ISO RTM permits evaluation of the depth and breadth of nursing care by identifying all nursing actions.

Modeling a terminology-based electronic nursing record system: An object-oriented approach

OBJECTIVE

The aim of this study was to present our perspectives on healthcare information analysis at a conceptual level and the lessons learned from our experience with the development of a terminology-based enterprise electronic nursing record system - which was one of components in an EMR system at a tertiary teaching hospital in Korea - using an object-oriented system analysis and design concept.

METHODS

To ensure a systematic approach and effective collaboration, the department of nursing constituted a system modeling team comprising a project manager, systems analysts, user representatives, an object-oriented methodology expert, and healthcare informaticists (including the authors). A rational unified process (RUP) and the Unified Modeling Language were used as a development process and for modeling notation, respectively.

RESULTS

From the scenario and RUP approach, user requirements were formulated into use case sets and the sequence of activities in the scenario was depicted in an activity diagram. The structure of the system was presented in a class diagram.

CONCLUSION

This approach allowed us to identify clearly the structural and behavioral states and important factors of a terminology-based ENR system (e.g., business concerns and system design concerns) according to the viewpoints of both domain and technical experts.

Nursing minimum data sets: a conceptual analysis and review

It is commonly acknowledged that nursing care is underrepresented in the healthcare record. The nursing minimum data set (NMDS) has been proposed as a method of routinely collecting information on core aspects of the nursing contribution to care, organised primarily in terms of phenomena, interventions and outcomes. Potential applications in clinical nursing, healthcare management, education and research have been identified. NMDS systems have been developed in a number of countries, with applications mostly related to resource allocation. To date, NMDS systems have tended to examine physical nursing care provided in institutional settings, with implications for construct and content validity. While NMDS research helps to clarify the nursing contribution to care, attention is now required to better understand the domains of nursing care across a broader range of care settings.

Mapping parish nurse documentation into the nursing interventions classification: a research method

Mapping, or linking like terms that represent the same concept, is a research method increasingly used for testing the reliability and validity of standardized taxonomies. For mapping to be useful, it is critical that the procedure is reliable. One way to maximize reliability is to develop standardized mapping procedures, or rules to follow when linking the terms. This article will present a standardized mapping procedure method in a study that mapped narrative parish nurse documentation (170 health records, 1607 interactions) into the Nursing Interventions Classification (NIC), yielding an intercoder reliability kappa of 0.92. The mapping process identified conceptual issues in the NIC, which also are presented. Because the NIC is included in the Systematic Nomenclature of Medicine of Clinical Terms (SNOMED CT), these conceptual issues raised data aggregation issues in SNOMED CT. Those issues are also presented.

Utility of a Standardized Nursing Terminology to Evaluate Dosage and Tailoring of an HIV/AIDS Adherence Intervention

PURPOSE

To illustrate the utility of a standardized nursing terminology to calculate the dosage of the Client Adherence Profiling-Intervention Tailoring (CAP-IT) and to determine the extent to which a tailored intervention was delivered to 117 persons with HIV/AIDS who participated in the experimental arm of a randomized controlled trial (RCT).

METHODS

The intervention nurse assigned nursing diagnoses from the Home Health Care Classification (HHCC) based upon CAP scores. During the IT phase of CAP-IT, the nurse delivered and documented a tailored set of nursing interventions associated with the CAP and assigned nursing diagnoses. Hierarchical linear regression was used to evaluate the extent to which the number of interventions and intervention times were tailored to client needs.

RESULTS

Linear regression models that included CAP scores and nursing diagnoses as predictor variables explained 53.2% of the variance in total number of interventions and 58.9% of the variance in intervention time.

CONCLUSIONS

The use of the standardized nursing terminology enabled calculation of the intervention dose and documentation that a tailored intervention was delivered.

Representing critical care data using the clinical care classification

Concept-oriented terminologies require the user to combine terms, making them awkward for their direct use as a documentation tool. Therefore, classification systems are needed to serve as interface terminologies between the user and the reference terminology used to organize the computer database system. Whether nursing classification systems provide sufficient granularity to adequately capture nursing practice is controversial. In addition, no nursing classification systems have been designed specifically for or evaluated in the critical care setting. The purpose of this study was to evaluate the ability of the Clinical Care Classification (CCC) to represent data in an intensive care setting and to provide recommendations for the expansion of this classification for its use in critical care documentation.

Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway

PURPOSE

The purpose of this analysis was to determine the adequacy of evolving national standardized terminologies with regard to coded data elements (concepts) in an automated clinical pathway designed to drive adherence with the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Evaluation and Management of Chronic Heart Failure.

METHOD

Concepts were identified in a previously developed automated clinical pathway and associated tools. Once identified, concepts were categorized according to the conceptual domains identified by Campbell et al. (1997). A review of evolving national standardized terminologies and coding systems was initiated to determine if the identified concepts had corresponding representation in one of these coding systems. Available codes were then evaluated for adequacy with respect to national guideline adherence measures put forth by the Centers for Medicare/Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

RESULTS

The concept domain model put forth by Campbell et al. (1997) worked well for organizing concepts and for providing a useful framework for data analysis. Using our method, 260 unique pathway concepts were identified, of which, 91.9% (239) are represented by one or more of the standardized coding systems. Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT alone represented 86.2% of the concepts. Seventy percent (70%) of the clinical pathway concepts are represented using the Health Insurance Portability and Accountability Act (HIPAA) mandated national terminologies alone. Less than 50% of CMS and JCAHO guideline adherence concepts were found to have representation in the HIPAA mandated terminologies. The addition of Logical Observation Identifier Names and Codes (LOINC) and SNOMED CT improved representation up to 86.4%, but did not include representation of all concepts necessary for complete electronic monitoring of guideline adherence.

CONCLUSIONS

Evolving national standardized terminologies provided matching terms for the majority of the data elements in the automated clinical pathway. Standard clinical terminologies with granular terms such as LOINC and SNOMED CT are required to represent the depth and detail of certain procedures and guideline-based care. Gaps exist in Health Insurance Portability and Accountability Act (HIPAA) mandated terminologies for representing interdisciplinary concepts in national adherence measures.

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.

Methods in informatics: using data derived from a systematic review of health care texts to develop a concept map for use in the neonatal intensive care setting

A qualitative systematic review of textbooks and clinical guidelines identified assessment criteria for initiation of nipple feeds in premature infants cared for in the neonatal intensive care unit (NICU) setting. Using a structured method for text source selection and data extraction, 43 health care texts were systematically reviewed yielding 153 separate statements related to assessing premature infants' feeding readiness. Following this procedure, a pile sort method was conducted wherein an expert neonatal nurse practitioner (NNP) grouped the statements according to similarity in meaning. Ten piles of terms emerged from this process. Each pile was "named," depicting discrete components used when assessing premature infants' readiness for nipple feeding. Using these public data and the private knowledge of the NNP informant, a concept map was constructed to illustrate a framework for decision support development and to examine the map's usefulness for structuring knowledge that will provide input to an intelligent decision support system.

Integrating nursing diagnostic concepts into the medical entities dictionary using the ISO Reference Terminology Model for Nursing Diagnosis

OBJECTIVE

The purposes of the study were (1) to evaluate the usefulness of the International Standards Organization (ISO) Reference Terminology Model for Nursing Diagnoses as a terminology model for defining nursing diagnostic concepts in the Medical Entities Dictionary (MED) and (2) to create the additional hierarchical structures required for integration of nursing diagnostic concepts into the MED.

DESIGN AND MEASUREMENTS

The authors dissected nursing diagnostic terms from two source terminologies (Home Health Care Classification and the Omaha System) into the semantic categories of the ISO model. Consistent with the ISO model, they selected Focus and Judgment as required semantic categories for creating intensional definitions of nursing diagnostic concepts in the MED. Because the MED does not include Focus and Judgment hierarchies, the authors developed them to define the nursing diagnostic concepts.

RESULTS

The ISO model was sufficient for dissecting the source terminologies into atomic terms. The authors identified 162 unique focus concepts from the 266 nursing diagnosis terms for inclusion in the Focus hierarchy. For the Judgment hierarchy, the authors precoordinated Judgment and Potentiality instead of using Potentiality as a qualifier of Judgment as in the ISO model. Impairment and Alteration were the most frequently occurring judgments.

CONCLUSIONS

Nursing care represents a large proportion of health care activities; thus, it is vital that terms used by nurses are integrated into concept-oriented terminologies that provide broad coverage for the domain of health care. This study supports the utility of the ISO Reference Terminology Model for Nursing Diagnoses as a facilitator for the integration process.

Building an expert system: a systematic approach to developing an instrument for data extraction from the literature

When building an expert system that will be acceptable to clinicians in their practice, it is imperative that the knowledge engineer identifies, defines, and describes a clinical problem precisely. This can be accomplished by eliciting private knowledge from expert clinicians or by analyzing public knowledge available in the scientific literature. This study describes a systematic method for examining public knowledge found in health care textbooks and practice guidelines surrounding the concept of oral feeding in premature infants in a neonatal intensive care unit. It includes the development of an instrument for extracting data from these sources to standardize definitions of terminologies. Preliminary results and plans for further analysis are reported. This method can be applied to other clinical problems deemed appropriate for decision support system development.

Testing the generalizability of the ISO model for nursing diagnoses

The purpose of this study was to explore whether the ISO reference terminology model for nursing diagnoses could be generalized to the MDS data set that, like nursing terminologies standardizes expressions of the concepts within and relevant to the domain of nursing practice. We first constructed paraphrased expressions of the rubrics from the data set. Next we dissected those expressions into the reference model domains of focus and judgment, recorded any qualifiers required for either domain, and semantic links required to represent associative relations. Our findings demonstrate that the ISO model for nursing diagnoses is generalizable to the MDS data set, however expansions to the model are required if the model is to be used to represent objects rather than terms.

An evaluation of the usefulness of two terminology models for integrating nursing diagnosis concepts into SNOMED Clinical Terms

OBJECTIVES

We evaluated the usefulness of two models for integrating nursing diagnosis concepts into SNOMED Clinical Terms (CT).

METHODS

First, we dissected nursing diagnosis term phrases from two source terminologies (North American Nursing Diagnosis Association Taxonomy 1 (NANDA) and Omaha System) into the semantic categories of the European Committee for Standardization (CEN) categorical structure and ISO reference terminology model (RTM). Second, we critically analyzed the similarities between the semantic links in the CEN and ISO models and the semantic links used to formally define diagnostic concepts in SNOMED CT.

RESULTS

Our findings demonstrated that focus, bearer/subject of information, and judgment were present in 100% of the NANDA and Omaha term phrases. The Omaha term phrases contained no additional descriptors beyond those considered mandatory in the CEN and ISO models. The comparison among the semantic links showed that SNOMED CT currently contains all but one of the semantic links needed to model the two source terminologies for integration. In conclusion, our findings support the potential utility of the CEN and ISO models for integrating nursing diagnostic concepts into SNOMED CT.

Minimum data set development: air transport time-related terms

The purpose of this research was to identify, name and define a set of concepts to describe specific times and time intervals relevant to patient transport by helicopter. A list of 206 potential terms was identified from 96 patient records. A purposive sample of experts representing nurses, physicians, paramedics, pilots and communication specialists involved in air transport was selected to participate in a five-round Delphi study conducted by email. A set of 19 concepts were identified and defined. Fifteen of the terms were specific times, such as Time of Call, Depart Base and Arrive Location. Four of the terms were intervals, such as Ground Time or Transport Time.

Cross-mapping the ICNP with NANDA, HHCC, Omaha System and NIC for unified nursing language system development. International Classification for Nursing Practice. International Council of Nurses. North American Nursing Diagnosis Association. Home Health Care Classification. Nursing Interventions Classification

Nursing language plays an important role in describing and defining nursing phenomena and nursing actions. There are numerous vocabularies describing nursing diagnoses, interventions and outcomes in nursing. However, the lack of a standardized unified nursing language is considered a problem for further development of the discipline of nursing. In an effort to unify the nursing languages, the International Council of Nurses (ICN) has proposed the International Classification for Nursing Practice (ICNP) as a unified nursing language system. The purpose of this study was to evaluate the inclusiveness and expressiveness of the ICNP terms by cross-mapping them with the existing nursing terminologies, specifically the North American Nursing Diagnosis Association (NANDA) taxonomy I, the Omaha System, the Home Health Care Classification (HHCC) and the Nursing Interventions Classification (NIC). Nine hundred and seventy-four terms from these four classifications were cross-mapped with the ICNP terms. This was performed in accordance with the Guidelines for Composing a Nursing Diagnosis and Guidelines for Composing a Nursing Intervention, which were suggested by the ICNP development team. An expert group verified the results. The ICNP Phenomena Classification described 87.5% of the NANDA diagnoses, 89.7% of the HHCC diagnoses and 72.7% of the Omaha System problem classification scheme. The ICNP Action Classification described 79.4% of the NIC interventions, 80.6% of the HHCC interventions and 71.4% of the Omaha System intervention scheme. The results of this study suggest that the ICNP has a sound starting structure for a unified nursing language system and can be used to describe most of the existing terminologies. Recommendations for the addition of terms to the ICNP are provided.

Initial validation of the perioperative nursing data set in Finland

PURPOSE

To explore the relevance of the Perioperative Nursing Data Set (PNDS) in Finland.

METHODS

A three-round Delphi technique (10 participants) and content analysis of 134 articles from the Journal of the Finnish Operating Room Nurses Association.

FINDINGS

All the PNDS outcomes, 86% of the diagnoses, and 87% of the interventions were found to be relevant. The Delphi panel suggested, and content analysis revealed, 6 new outcomes, 43 new diagnoses, and 11 new interventions. Consensus was achieved on 77%. The phrases used in perioperative articles corresponded with those of PNDS 56%-78% of the time.

CONCLUSIONS

PNDS can be used to describe perioperative nursing in Finland. Further conceptualization and validation are needed before using the data set in perioperative practice.

IMPLICATIONS FOR PRACTICE

Although PNDS cannot be implemented in Finland as is, it is a valid structure for further development of the terminology, contents, methods, and practice of Finnish perioperative documentation.

Information model and terminology model issues related to goals

Goal statements are a significant component of structures that support the process of health care delivery such as practice guidelines, standards of care, critical pathways, disease management plans, patient education plans, and nursing care plans. Although these structures are increasingly computer-based, there has been little attention to the formal representation of goal statements. This is a necessary prerequisite for enabling semantic interoperability. Existing and evolving information model and terminology model standards offer some approaches that may be applicable to goal statements, however, a number of issues require resolution

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.

Accessing heterogeneous sources of evidence to answer clinical questions

The large and rapidly growing number of information sources relevant to health care, and the increasing amounts of new evidence produced by researchers, are improving the access of professionals and students to valuable information. However, seeking and filtering useful, valid information can be still very difficult. An online information system that conducts searches based on individual patient data can have a beneficial influence on the particular patient's outcome and educate the healthcare worker. In this paper, we describe the underlying model for a system that aims to facilitate the search for evidence based on clinicians' needs. This paper reviews studies of information needs of clinicians, describes principles of information retrieval, and examines the role that standardized terminologies can play in the integration between a clinical system and literature resources, as well as in the information retrieval process. The paper also describes a model for a digital library system that supports the integration of clinical systems with online information sources, making use of information available in the electronic medical record to enhance searches and information retrieval. The model builds on several different, previously developed techniques to identify information themes that are relevant to specific clinical data. Using a framework of evidence-based practice, the system generates well-structured questions with the intent of enhancing information retrieval. We believe that by helping clinicians to pose well-structured clinical queries and including in them relevant information from individual patients' medical records, we can enhance information retrieval and thus can improve patient-care.

Integration of nursing assessment concepts into the medical entities dictionary using the LOINC semantic structure as a terminology model

Recent investigations have tested the applicability of various terminology models for the representing nursing concepts including those related to nursing diagnoses, nursing interventions, and standardized nursing assessments as a prerequisite for building a reference terminology that supports the nursing domain. We used the semantic structure of Clinical LOINC (Logical Observations, Identifiers, Names, and Codes) as a reference terminology model to support the integration of standardized assessment terms from two nursing terminologies into the Medical Entities Dictionary (MED), the concept-oriented, metadata dictionary at New York Presbyterian Hospital. Although the LOINC semantic structure was used previously to represent laboratory terms in the MED, selected hierarchies and semantic slots required revisions in order to incorporate the nursing assessment concepts. This project was an initial step in integrating nursing assessment concepts into the MED in a manner consistent with evolving standards for reference terminology models. Moreover, the revisions provide the foundation for adding other types of standardized assessments to the MED.

Structural validation of nursing terminologies

OBJECTIVE

The purpose of the study is twofold: 1) to explore the applicability of combinatorial terminologies as the basis for building enumerated classifications, and 2) to investigate the usefulness of formal terminological systems for performing such classification and for assisting in the refinement of both combinatorial terminologies and enumerated classifications.

DESIGN

A formal model of the beta version of the International Classification for Nursing Practice (ICNP) was constructed in the compositional terminological language GRAIL (GALEN Representation and Integration Language). Terms drawn from the North American Nursing Diagnosis Association Taxonomy I (NANDA taxonomy) were mapped into the model and classified automatically using GALEN technology.

MEASUREMENTS

The resulting generated hierarchy was compared with the NANDA taxonomy to assess coverage and accuracy of classification.

RESULTS

In terms of coverage, in this study ICNP was able to capture 77 percent of NANDA terms using concepts drawn from five of its eight axes. Three axes-Body Site, Topology, and Frequency-were not needed. In terms of accuracy, where hierarchic relationships existed in the generated hierarchy or the NANDA taxonomy, or both, 6 were identical, 19 existed in the generated hierarchy alone (2 of these were considered suitable for incorporation into the NANDA taxonomy and 17 were considered inaccurate), and 23 appeared in the NANDA taxonomy alone (8 of these were considered suitable for incorporation into ICNP, 9 were considered inaccurate, and 6 reflected different, equally valid perspectives). Sixty terms appeared at the top level, with no indenting, in both the generated hierarchy and the NANDA taxonomy.

CONCLUSIONS

With appropriate refinement, combinatorial terminologies such as ICNP have the potential to provide a useful foundation for representing enumerated classifications such as NANDA. Technologies such as GALEN make possible the process of building automatically enumerated classifications while providing a useful means of validating and refining both combinatorial terminologies and enumerated classifications.

From data to knowledge through concept-oriented terminologies: experience with the Medical Entities Dictionary

Knowledge representation involves enumeration of conceptual symbols and arrangement of these symbols into some meaningful structure. Medical knowledge representation has traditionally focused more on the structure than the symbols. Several significant efforts are under way, at local, national, and international levels, to address the representation of the symbols though the creation of high-quality terminologies that are themselves knowledge based. This paper reviews these efforts, including the Medical Entities Dictionary (MED) in use at Columbia University and the New York Presbyterian Hospital. A decade's experience with the MED is summarized to serve as a proof-of-concept that knowledge-based terminologies can support the use of coded patient data for a variety of knowledge-based activities, including the improved understanding of patient data, the access of information sources relevant to specific patient care problems, the application of expert systems directly to the care of patients, and the discovery of new medical knowledge. The terminological knowledge in the MED has also been used successfully to support clinical application development and maintenance, including that of the MED itself. On the basis of this experience, current efforts to create standard knowledge-based terminologies appear to be justified.

Evaluation of the clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures

OBJECTIVE

The purpose of this study was to test the adequacy of the Clinical LOINC (Logical Observation Identifiers, Names, and Codes) semantic structure as a terminology model for standardized assessment measures.

METHODS

After extension of the definitions, 1, 096 items from 35 standardized assessment instruments were dissected into the elements of the Clinical LOINC semantic structure. An additional coder dissected at least one randomly selected item from each instrument. When multiple scale types occurred in a single instrument, a second coder dissected one randomly selected item representative of each scale type.

RESULTS

The results support the adequacy of the Clinical LOINC semantic structure as a terminology model for standardized assessments. Using the revised definitions, the coders were able to dissect into the elements of Clinical LOINC all the standardized assessment items in the sample instruments. Percentage agreement for each element was as follows: component, 100 percent; property, 87.8 percent; timing, 82.9 percent; system/sample, 100 percent; scale, 92.6 percent; and method, 97.6 percent.

DISCUSSION

This evaluation was an initial step toward the representation of standardized assessment items in a manner that facilitates data sharing and re-use. Further clarification of the definitions, especially those related to time and property, is required to improve inter-rater reliability and to harmonize the representations with similar items already in LOINC.

Embedded structures and representation of nursing knowledge

Nursing Vocabulary Summit participants were challenged to consider whether reference terminology and information models might be a way to move toward better capture of data in electronic medical records. A requirement of such reference models is fidelity to representations of domain knowledge. This article discusses embedded structures in three different approaches to organizing domain knowledge: scientific reasoning, expertise, and standardized nursing languages. The concept of pressure ulcer is presented as an example of the various ways lexical elements used in relation to a specific concept are organized across systems. Different approaches to structuring information-the clinical information system, minimum data sets, and standardized messaging formats-are similarly discussed. Recommendations include identification of the polyhierarchies and categorical structures required within a reference terminology, systematic evaluations of the extent to which structured information accurately and completely represents domain knowledge, and modifications or extensions to existing multidisciplinary efforts.

An evaluation of ICNP intervention axes as terminology model components

In this paper we evaluate selected axes of the International Classification of Nursing Practice (ICNP) as terminology model components for nursing actions by dissecting and categorizing two data sets of term phrases (Patient Care Data Set and Home Health Care Classification). Second, we critically analyze the relationships between the ICNP axes and terminology model components used to formally define procedures (including nursing actions) in SNOMED RT. Our findings demonstrate that the semantic categories represented by the ICNP intervention axes are relevant sources for terminology model components for nursing actions. In addition, our findings suggest that only minimal additions or extensions to the current semantic links of SNOMED RT are needed to support the formal definition of nursing actions such as those contained in PCDS and HHCC.