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Lecture 5

Standardized Terminology and
Language in Health Care
(Chapter 15)
http://www.csun.edu/~dn58412/IS531/IS531_S
P16.html

Learning Objectives
1. Standardized healthcare terminology and
its importance
2. Languages and Classifications : Billing,
Clinical, Nursing
3. Terminology structures: Classification
System vs. Reference Terminology
4. Benefits of using structured terminologies
within electronic healthcare records.
5. Issues and concerns
IS 531 : Lecture 5

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Standardized Terminology
• Also called “Controlled Terminology”
• Structured and controlled languages
developed and approved by an authoritative
body
• Healthcare terminology standards designed
to enable and support interoperability and
information sharing
• Essential to the widespread implementation
of EHRs
IS 531 : Lecture 5

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Healthcare Terminology
Standards
• To represent, communicate, exchange,
manage and report data information, and
knowledge in healthcare
• Ensure accurate, valid data collection
among various providers and care settings
• Meaningful Use: exchange clinical
structured data in an accurate and
complete manner to improve costefficiency in client care
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.Terminology Definitions . . • Concept: an expression with a single unambiguous meaning • Code: letters/characters/both to represent a concept – Codified concepts • Clinical terminology: describe health conditions and healthcare activities • Ontology: concepts are organized by their meaning describe a definitional structurerelationship IS 531 : Lecture 5 5 .

and specialties • Point-of-care Terminology (interface terminology): reference terminology in familiar term to clinicians – to support the entry of patient-related information into a computer program IS 531 : Lecture 5 6 . . .. domains.Terminology Definitions • Reference Terminology: a set of concepts with definitional relationship – To retrieve data across healthcare settings.

Types of Healthcare Terminologies IS 531 : Lecture 5 7 .

Technology Development Guidelines IS 531 : Lecture 5 8 .

and outcomes • To support interoperability. sharing comparable data with other healthcare organizations IS 531 : Lecture 5 9 .Terminology and Nursing • Different terms indicate the same thing ! • Need a standardized nursing language to describe care across clinical settings and specialists • How to document nursing problems. interventions.

.Languages and Classifications . • Billing Codes – Mandated by Health Insurance Portability and Accountability Act (HIPAA) – International Classification of Disease (ICD) by World Health Organization (WHO): • for diagnosis reimbursement – Current Procedural Terminology (CPT) American Medical Association(AMA): • for billing and reimbursement of outpatient procedures and interventions IS 531 : Lecture 5 10 . .

ICD Examples IS 531 : Lecture 5 11 .

CPT Examples IS 531 : Lecture 5 12 .

and Codes (LOINC) IS 531 : Lecture 5 13 . .Languages and Classifications . • Clinical Terminologies – Unified Medical Language Systems (UMLS) by National Library of Medicines (NLM). . recognized by American Nurses Association (ANA) – Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT) – Logical Observation Identifiers. Name.

305) • Using parent-child relationship to build vertical hierarchies IS 531 : Lecture 5 14 . and relationships) • Recognized by ANA • Promotes evidence-based practice • Undergoes review process to keep up to date • SNOMED-CT consists of 19 top-level hierarchies (Cf. descriptions. p.SNOMED-CT • Globally recognized terminology (concepts.

SNOMED-CT Example IS 531 : Lecture 5 15 .

test result. Names. IS 531 : Lecture 5 16 . and Codes” • Terminologies for laboratory and clinical observations • For recording a single observation.LOINC • “Logical Observation Identifiers. measurement.

LOINC Examples IS 531 : Lecture 5 17 .

. • Nursing Terminologies – Clinical Care Classification (CCC) – International Classification of Nursing Practice (ICN) – North American Nursing Diagnosis Association International (NANDA-I) – Nursing Intervention Classification (NIC) – Nursing Outcome Classification (NOC) – Omaha System – Perioperative Nursing Data Set (PNDS) IS 531 : Lecture 5 18 .Languages and Classifications . .

Clinical Care Classification (CCC) System • To facilitate patient care documentation at the point of care • CCC of nursing diagnosis and outcome: – 182 diagnosis concepts in categories and subcategories. treatments. 3 outcome qualifiers. IS 531 : Lecture 5 19 . and activities. • CCC for nursing intervention: – 198 concepts in categories and sub-categories to represent interventions. procedures.

actions. and outcomes in 7 axes (dimensions) IS 531 : Lecture 5 20 .International Classification of Nursing Practice (ICNP) • For point-of-care and reference terminology • Contains diagnoses.

ICNP Examples IS 531 : Lecture 5 21 .

7 axes(dimensions) IS 531 : Lecture 5 22 .NANDA-I • “North American Nursing Diagnosis International” • Each nursing diagnosis actual or potential health problem has: description. defining characteristics (manifestations. symptoms) • 13 domains . definition. signs.

NANDA Domains IS 531 : Lecture 5 23 .

NANDA-I Examples IS 531 : Lecture 5 24 .

Nursing Interventions Classification (NIC) • Describe interventions used in nursing care • 30 classes. 7 domains and 542 interventions IS 531 : Lecture 5 25 .

NIC Domains IS 531 : Lecture 5 26 .

measurement scale. associated indicators. supporting references IS 531 : Lecture 5 27 .Nursing Outcomes Classification (NOC) • Describe outcomes related to nursing interventions • 31 classes and 7 domains of outcomes • Each outcome has: definition.

NOC Domains IS 531 : Lecture 5 28 .

Omaha System • Research-based taxonomy for integrating and sharing clinical data • Assessment component—Problem Classification Scheme • Intervention component—Intervention Scheme • Outcomes component—Problem Rating Scale for Outcomes IS 531 : Lecture 5 29 .

Omaha Systems IS 531 : Lecture 5 30 .

and 27 nurse-sensitive patient care outcomes IS 531 : Lecture 5 31 . 75 diagnoses. interventions.Perioperative Nursing Data (PNDS) Set • Provide wording and definitions for nursing diagnoses. 135 interventions. and outcomes • Allow collection data in a uniform way for analyses • 4 components.

PNDS Example IS 531 : Lecture 5 32 .

Benefits of Implementation • Client-specific benefits – Decreased costs – Increased quality – Improved outcomes – Improved safety IS 531 : Lecture 5 33 .

Benefits of Implementation • Provider/Nursing Benefits – Complete access to data – Increased efficiency – Increased accuracy – Increased effectiveness – Improvement in client care IS 531 : Lecture 5 34 .

Benefits of Implementation • Organizational Benefits – Decreased costs – Decision support – Outcome measurement – Data mining IS 531 : Lecture 5 35 .

not using standard terminology • Select which terminology(ies) to use • Point-of-care terms and synonyms for clinical tasks must be locally developed: potential problems for other local systems IS 531 : Lecture 5 36 .Issues and Concerns • Integrate systems with locally defined concepts.

Nursing Assessment Examples IS 531 : Lecture 5 37 .

Nursing Diagnosis/Problem Examples IS 531 : Lecture 5 38 .

Nursing Intervention Examples IS 531 : Lecture 5 39 .

Nursing Goal/Potential Outcome Examples IS 531 : Lecture 5 40 .