BACHELOR OF SCIENCE IN NURSING:

NURSING INFORMATICS
COURSE MODULE COURSE UNIT WEEK
2 9 10

Standardizing Healthcare Data and Terminologies in Nursing Informatics Practice

Read course and unit objectives

Read study guide prior to class attendance
Read required learning resources; refer to unit
terminologies for jargons
Proactively participate in classroom discussions
Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Define data standards in the healthcare profession point of view
2. Differentiate syntax from semantics
3. Enumerate categories of standards
4. Cite organizations dedicated to standardization of healthcare data
5. Describe the impact of standardizations of healthcare data
6. Understand the basics of nursing minimum data set
7. Correlate nursing terminologies and relevance to nursing practice
8. Identify components of advanced terminology systems in nursing
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class

Saba, V., and McCormick, K. (2006) Essentials of Nursing Informatics 4th Edition, Overview of
Computers and Nursing, Historical Perspectives of Nursing and Computer (pp 70-84). New York:
McGraw-Hill Companies

Healthcare Data Standards

The healthcare field has a long history of establishing data standards. Data standards as applied to
healthcare include methods, protocols, terminologies and specifications for the collection,
exchange, storage and retrieval of information associated with the healthcare applications
including medical records, medications, radiological images, payment and reimbursement, medical
devices, monitoring systems and administrative process.

It is important however for nurses to understand the basic of standards. Key decisions must be
made to about how and when standards should be implemented to assure quality care.

Categories of Standards

Interoperability in healthcare depends on two important concepts:

• Syntax - refers to structure of communication; the equivalent of rules in spelling and

grammar

• Semantics – convey the meaning of communication; the equivalent of dictionary and

thesaurus

The available healthcare standards today address both types of interoperability. Healthcare
standards are categorized into six (6):
 • Data Exchange / Messaging Standards – these allow transactions to flow consistently
between systems or organizations because they contain instructions for format, data,
elements, and structure. Common standards includes HL and for administrative data such
as patient demographics or encounters; DICOM for radiology images and NCPDP for
electronic prescriptions.

• Terminology Standards – these vocabularies provide specific codes for clinical concepts
such as diseases, problem list, allergies, medications, and diagnoses that might have
varying textual descriptions in a paper chart or a transcription. Examples of terminologies
are LOINC for lab results; SNOMED for clinical terms; and ICD for medical diagnoses.

• Document Standards – these indicate what type of information is included in a document

and where it can be found. A common standard in paper medical records in the SOAP
(Subjective, Objective, Assessment, Plan) format. The CCR (Continuity of Care Record)
provides a standard format for inter-provider communication, including patient identifying
information, medical history, current medications, allergies, and a care plan
recommendation.

• Conceptual Standards – these allow data to be transported across systems without losing
meaning and context. For example, the HL7 RIM (Reference Information Model) provides a
framework for describing clinical data and the context surrounding it.

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

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

Impact of Clinical Data Standards

The comprehensive patient record accommodates the patients’ movement among all locations
where care is provided: inpatient, outpatient, and clinic settings. This allows the healthcare
organization to conduct outcome analysis with comparable data. Instead of conducting manual
chart reviews and relying on individual interpretation of narrative notes, the system provides
semantically consistent data that can be analyzed.
There are also unintended benefits. The improved charting has led to better charge capture, since
changes are a function of documentation and not a separate activity. And, by bringing various
regions together to plan and design the system, staff have come to see each other as internal
consultants who share best practices on policies and procedures, patient education programs, and
preparation for accreditation visits. A planned single medication list per patient will cover inpatient
and outpatient environments; it is expected to improve case management, prevent adverse drug
interactions, and enhance patient satisfaction.

Organizations on Standardizing Healthcare Data

Standards have been created by variety of healthcare organizations including service delivery
entities, regulators, vendors and consultants. Typically, the standards development involves
technical committee that defines methods, and groups organized around the communities of
interest. Representing stakeholders in these development projects are clinicians, researchers,
bioinformaticist, chief information officers, database administrators, information systems analyst,
and project managers. In addition, special interest entities in public health, patient safety, and
electronic health records work to ensure that the standards are relevant to practice in those areas.

Nursing Minimum Data Set

Information technology can have a positive impact on the quality and efficiency of today’s health care
system. In addition, large savings may be realized by moving from a paper-based system to
electronic records. Data in electronic or digital form provides an efficient method of storing, retrieving,
analyzing, and archiving data for student populations. Electronic records support the transformation
of data into information and knowledge that can enhance the quality of nursing care. The use of a
common vocabulary to gather data will assist in validating the contributions of school nurses to
student health and educational outcomes.

The Nursing Minimum Data Set (NMDS) is a current standardization effort. The American Nurses
Association Steering Committee on Databases to Support Clinical Practice (ANASCD) is involved in
developing the NMDS. This set is described as "the minimum data elements necessary for defining
the cost and quality of nursing care." Elements of the NMDS include the following:

• Nursing Care Elements

o Nursing Diagnosis
o Nursing Intervention
o Nursing Outcome
o Intensity of Nursing Care
• Patient Demographic Elements

o Personal identification
o Date of Birth
o Sex
o Race and ethnicity
o Residence

• Service Elements

o Unique facility or agency number elements

o Unique patient health record number
o Unique number of principle RN
o Episode encounter date
o Discharge or termination date
o Disposition of patient
o Expected payer for this bill

In 1991 the American Nurses Association (ANA) created a committee to review nursing languages
and to recognize those that had met the committee’s own criteria as potentially useful to support
nursing practice. Since that time, the ANA criteria have evolved with the growing knowledge of
terminology standards in health informatics. Standardized terminologies are bulleted below:

• NANDA - (diagnoses from the North American Nursing Diagnosis Association). While ICD-9-
CM codes describe a disease or injury, NANDA nursing diagnoses describe a patient's
reactions to the disease and to treatment.

• NIC - (Nursing Interventions Classification) is a standardized language for treatments that

nurses perform. NIC was developed at the University of Iowa and information is published by
Mosby, There is a section of that University's Nursing Web site devoted to NIC and NOC.

• NOC - (Nursing Outcomes Classification). Also developed at the University of Iowa. It goes
beyond the work of NIC toward classification of outcomes useful in clinical nursing.

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

• Saba’s Home Healthcare – the Home Health Care Classification of Nursing Diagnoses and
Interventions (HHCC), developed at Georgetown University, focuses on community health.
• UMLS Metathesaurus - The National Library of Medicine UMLS Metathesaurus includes terms
from NANDA, NIC, NOC, HHCC, and others.

• Clinical Care Classification - The Clinical Care Classification (CCC) System is a

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

• Perioperative Nursing Data Set (PNDS) - Describes perioperative nursing practice with a sub-
set of terms that specifically describe perioperative nursing diagnoses, nursing interventions,
and patient outcomes in surgical settings from pre-admission until discharge.

• SNOMED CT - (Systematized Nomenclature of Medicine-Clinical Terms) is considered to be

the most comprehensive, multilingual clinical healthcare terminology in the world.

• PCDS - The Patient Care Data Set (version 4.0, 1998) contains a data dictionary and sets of
terms and codes representing specific values of Patient Problems (363 terms), Patient Care
Goals (311 terms), and Patient Care Orders (1357 terms). It was recognized in 1998 by the
American Nurses Association (ANA) as one of the vocabularies to be considered for use by
nurses, and is included in the National Library of Medicine's Metathesaurus.

• International Classification for Nursing Practice – The ICNP is a combinatorial terminology

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

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

The primary motivation for standardized terms in nursing is the need for valid, comparable data
that can be used across information system applications to support clinical decision making and
the evaluation of process and outcomes of care.

Concept-Oriented Terminology in Nursing Informatics

The health informatics literature provides an evolving framework that enumerates the criteria that
render healthcare terminologies suitable for implementation in computer-based systems. The
relationship will be best described by the professor using the semiotic triangle:
A single concept may be associated with multiple terms (synonymy); however, a term should
represent only one concept.

In order to appreciate the significance of concept-oriented approaches, it is important for nurses to

understand the definitions of and relationship among things in the world (objects), his thoughts
about things in the world (concepts) and the labels nurses use to represent and communicate
thoughts about things in the world (terms).

The following terminologies may be helpful to define relationships:

• Concept – thought or reference; unit of knowledge created by a unique combination of

characteristics (an abstraction of a property of an object or of a set of objects.)
• Objects – the referent; anything perceivable or conceivable.
• Term – the symbol; verbal designation of a general concept corresponds to two or more
objects which form a group by reason of common properties.

Components of Advanced Terminology Systems

Within the context of the high-level information model, there has been extensive development and
refinement of terminologies for describing patient problems, nursing interventions and nursing
sensitive patient outcomes. The main component of more advanced terminology systems is a
concept-oriented terminology model for ontology representing a set of concepts and their inter-
relationships. The components of advanced terminology systems for the nursing practice are as
follows:

• Terminology Model – concept-based representation of domain-specific terms that is optimized

for the management of terminology definitions. It encompasses:
o Schemata – incorporate domain-specific knowledge about the typical constellation of
entities, attributes and events in the real world and reflect plausible combinations of
concepts. Example: “pain” can be combined with “acute” to make “acute pain”.
o Type Definitions – are obligatory conditions that state only the essential properties of the
concept. Example: a nursing activity must have a recipient, an action and a target.
 Representation Language – terminology models may be formulated and elucidated in an
ontology language. Ontology language represents classes and their properties. In this way,
ontology languages are able to support, though explicit semantics, the formal definition of
concepts in terms of their relationships with another concept.

Computer-Based Tools – a representation language may be implemented using description

logic within a software system or by a suite of software tools.

Nursing Minimum Data Set (NMDS) - a classification system which allows for the standardized
collection of essential nursing data. The collected data are meant to provide an accurate
description of the nursing process used when providing nursing care.

Covits, P. (2003), A common infrastructure, Bioinformatics Electronic Journal Vol. 18 No. 18, pp
2404-2412

National Association of School Nurses (NASN). (2001). Position statement: Nursing Classification
Systems: North American Nursing Diagnosis Association (NANDA), Nursing Interventions
Classification (NIC), and Nursing Outcomes Classification (NOC). Available at
http://www.nasn.org/Default.aspx?tabid=233

• Create a “Concept Map” focusing on the guidelines for dependable system based on your own
point of view of this unit’s discussion

ACEP (2008), Healthcare Data Standards and Interoperable Systems, Retrieved October 14, 2019
from American College of Emergency Physicians Webpage; Website:
http://www.acep.org/practres.aspx?
id=29498

HIMMS (2004), National health Information Infrastructure, Survey Results, California Healthcare
Foundation Oakland.
Saba, V., and McCormick, K. (2006) Essentials of Nursing Informatics 4th Edition, Healthcare Data
Standards, Dependable Systems for Quality Care, Nursing Minimum Data Sets (217-261). New
York: McGraw-Hill Companies

Androwich, I.M., Averill, C., Carty, B., Delaney, C., Donaldson, N.E., Gibbons, B.J., et al. (2003).
Nursing Information and Data Set Evaluation Center (NIDSEC) standards and scoring guidelines.
Washington, DC: American Nurses Publishing.

National Association of School Nurses (NASN). (2001). Position statement: Nursing Classification
Systems: North American Nursing Diagnosis Association (NANDA), Nursing Interventions
Classification (NIC), and Nursing Outcomes Classification (NOC). Available at
http://www.nasn.org/Default.aspx?tabid=233

Kellum, S. (2008), Nursing Classification Systems, Retrieved October 16, 2019 from NCNA
Webpage, Website: http://personal.uncc.edu/macurran/
macurran3/coni/nmds.htm

Saba, V. (2008), Clinical Care Classification, Retrieved October 15, 2019 from SabaCare
Webpage, Website:
http://www.sabacare.com/index.html

AORN (2008), Terminology: Perioperative Nursing Data Set (PNDS), Retrieved October 16, 2019
from American Operative Nurses Association Webpage, Website:
http://www.nursingworld.org/npii/pnds.htm

SNOMED-CT (2008), SNOMED-CT, Retrieved October 16, 2019 from International Health
Terminology Standards Development Organization Webpage, Website:
http://www.ihtsdo.org/snomed-ct/