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Development, Evaluation, and Use of Reference Terminology for Nursing

Progress Report from the Nursing Terminology Summit

Nursing Terminology Summit 2002 Report to AMIA

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Today¶s Panel 
 

Overview of the Summit The Big Picture: Key Concepts Developing and Evaluating Models 
 

A Domain Concept Model for Findings Models for Nursing Actions A Model of the Nursing Process 



From Models to Reference Terminology From Reference Terminology to Terminology Systems 


Advances in Commercial Systems Terminology Systems in Clinical Applications
Nursing Terminology Summit 2002 Report to AMIA 2

Overview of the Summit

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The Nursing Terminology Summit Annual meetings since 1999  Participants from 5 continents  Diverse expertise and work settings  Nursing Terminology Summit 2002 Report to AMIA 4 .

Chair Ida Androwich Suzanne Bakken Patricia Button Nicholas Hardiker Charles Mead Judith Warren Christine Zingo Nursing Terminology Summit 2002 Report to AMIA 5 .Summit Steering Committee         Judy Ozbolt.

Summit Sponsors       NLM HRSA AMA AMIA* Cerner* HIMSS      IDX 3M McKesson* Siemens* SNOMED* *Sponsor in 2002 Nursing Terminology Summit 2002 Report to AMIA 6 .

Mission of the Nursing Terminology Summit  Promote and support the development. and use of reference terminology for nursing and  the integration of reference nursing terminology with healthcare applications and with other healthcare terminological systems  Nursing Terminology Summit 2002 Report to AMIA 7 . evaluation.

setting directions for development to be done elsewhere  Worldwide scope  Expert authority (no formal authority)  Nursing Terminology Summit 2002 Report to AMIA 8 . coordinating.The Summit¶s Methods of Work Annual meeting  Intervening collaboration  Think tank for resolving questions.

and use reference terminology for nursing Nursing Terminology Summit 2002 Report to AMIA 9 . evaluate. integrate.The Summit¶s Aims     Coordinate efforts to develop and integrate standards that involve formal nursing terminology Promote collaboration Disseminate knowledge gained Take home understanding of how work done in local setting fits into global efforts to develop.

now a Draft Standard Use of terminology models to guide development of terminology in SNOMED and elsewhere Nursing Terminology Summit 2002 Report to AMIA 10 . LOINC Nursing terminology models submitted to ISO committee in 2002.Collaborative Progress since 1999      IMIA/ICN proposal to ISO in 2000 Integration of CEN work into ISO work in 2001 Integration of nursing concepts and nursing leadership into HL7.

and Use of Reference Terminology: The Big Picture Nursing Terminology Summit 2002 Report to AMIA 11 .Development. Evaluation.

and sanctions describing potential characteristics for representing concepts in a domain Reference Terminology Model: Domain concept model that is optimised for terminology management Dissection: Systematic representation of a phrase according to a predefined domain concept model Nursing Terminology Summit 2002 Report to AMIA 12 .Key Definitions (ISO CD 17115)    Domain Concept Model: set of formal categories. semantic links.

Building on the Models    Terminology model: represents concepts and definitional relationships Reference terminology: populates model with words representing instances of concepts and relationships Terminology system: software to manipulate concepts and relationships   Functions limited to processing terminology Distinct from application systems with which it interacts Nursing Terminology Summit 2002 Report to AMIA 13 .

Dissect terms from nursing classifications and other vocabularies according to models to create formal representations. Nursing Terminology Summit 2002 Report to AMIA 14  Methods:    . Integrate formal representations from many sources within standards developing organizations. Create controlled vocabularies from common expressions and dissect those expressions.Development of Reference Terminology for Nursing  Goal:  Populate models with words representing instances of the concepts.

and conceptualizations  Must lead to coherent and growing body of knowledge  Nursing Terminology Summit 2002 Report to AMIA 15 . expressions.Evaluation of Reference Terminology for Nursing Iterative and continual  Test and retest models.

 Nursing Terminology Summit 2002 Report to AMIA 16 . and clarify operations and transactions.Use of Reference Terminology for Nursing Installed in terminology systems (software) that interact with application systems (different but compatible software)  Formal modeling processes help to define the functions of each system. identify optimal placement of functions.

Potential Functions of a Reference Terminology System     Link interface expressions and statistical classifications to their formal. reference definitions Generate compositional expressions from atomic concepts Map between expressions in different terminologies and their formal representations in the reference terminology Compare and harmonize among terminologiesNursing Terminology Summit 2002 Report to AMIA 17 .

Developing and Evaluating the Models Progress at the Summit. 1999-2002 Nursing Terminology Summit 2002 Report to AMIA 18 .

Warren Nursing Terminology Summit 2002 Report to AMIA 19 . Goals.A Domain Concept Model for Findings: Similarities and Differences among Diagnoses. and Outcomes Judith J.

and Goals Findings (observation) O1A O1A X X X O2A O2A OE OE-O2A Outcome Goal Goal Variance O=observation. Outcomes.Findings. E=expected Nursing Terminology Summit 2002 Report to AMIA 20 . X=intervention. A=actual.

but in the information model Outcome has links to the baseline value and to the Intervention  Nursing Terminology Summit 2002 Report to AMIA 21 . but in the information model Goal differs in timing and mood  Outcome is no different from Finding in the terminology model.Conclusions Goal is no different from Finding in the terminology model.

Findings Reference Terminology Model Dimension Subject of Information Focus Value Site Method Derivation Nursing Terminology Summit 2002 Report to AMIA 22 .

Nursing Diagnosis Reference Terminology Model Dimension Subject of Information Focus Judgment Site Nursing Terminology Summit 2002 Report to AMIA 23 .

Terminology and Information Models for Nursing Actions: The Use-Case Approach to Development and Testing Pat Button Nursing Terminology Summit 2002 Report to AMIA 24 .

from both terminological and structural perspectives. Nursing Terminology Summit 2002 Report to AMIA 25 . In 2000. initiated focused work on the harmonization of emerging nursing terminology models with the RIM of HL7:  Approach: testing the extent to which the RIM supports the expression and communication of nursing actions (interventions).Summit Interventions Group   Group has focused on nursing interventions since initial Summit meeting in 1999.

Nursing Terminology Summit 2002 Report to AMIA 26 .Goal of the Intervention Team  Ensure that the HL7 RIM supports nursing terminology and that it provides a foundation for integrating nursing intervention concepts.

Objectives  Provide feedback to HL7 regarding the ability of the RIM to:    Express nursing interventions (focus: education) Express the full range of nursing interventions in patient education Express other nursing interventions and potentially support other disciplinary interventions Nursing Terminology Summit 2002 Report to AMIA 27 .

use case development)  Nursing Terminology Summit 2002 Report to AMIA 28 .g.Approach Analyze a random selection of interventions from existing classification systems for fit with HL7 RIM  Selected ³Patient Education´ as intervention for further action (e.

2001) to validate HL7-RIM¶s ability to represent the intervention (instance diagrams) Initiated submission process for Education Use Cases at HL7 Patient Care Committee Terminology Summit Nursing 2002 Report to AMIA 29 .Approach     Created high level education Use Cases (N=6) Validated Education Use Cases based on expert/group feedback Used Nine-Step Model (Russler.

Nursing Terminology Summit 2002 Report to AMIA 30 .Assumptions  Use cases for breast cancer education can provide an adequately robust test case to understand the information model terminology issues related to nursing interventions.

Agreement on final educational plan 10. manager of the oncology inpatient floor. 9. VP of nursing. Director of the Oncology clinic. Sequence: A literature review is performed to collect current education research and best practices. ‡ An oncology education standards committee was formed ‡ Members include Chief Oncologist. NCI. Iterative review process with team members.Use Case 1 .Develop Education Plan Pre conditions: ‡ Breast cancer patients were chosen for the first education standard. 5. The links should be context specific. Research external requirements from organizations like JCAHO. HCFA. and existing educational materials 4. Post conditions: 12. Clinical Pharmacists. requirements. Research patient education materials prepared by other organizations like the American Cancer Society. Manager of oncology homecare services. method. Report to AMIA 1. Director of OR services. Link finalized education plan to problem list 11. Gain agreement if standard terminology will be used. Draft initial template for educational interventions. 8. Include the intervention. Review and modify on a regularNursing Terminology Summit basis. . Provide links from standard plan to education knowledge bases. Advanced Practice Nurses. 2002 31 ‡ Add to repository of education plans. responsibility. 3. VP of ancillary services. 2. intensity. measurement criteria and an example of expected outcome. 6. Evaluate compliance with standards. Collect internal policies. FDA. 7. Oncology Nursing Society or 3rd party payers. and large volume 3rd party payers.

& large volume 3rd party payers. include in plan or No. do not include :Any value: :Any value: :Any value: Nursing Terminology Summit 2002 Report to AMIA Yes. FDA.Use Case 1 . 2) Research external requirements: JCAHO. include Yes. requirements. do not include do not include do not include . include Yes. 3)Collect internal policies. in plan or No. NCI. HCFA.Research to Define Best Plan Role code :Committee Evaluates Evaluates Observation Evaluates Evaluates Repeated for each review source for inclusion in the education plan Participation typeCode :Author Procedure Observation Observation Observation code : Breast Cancer : Literature Education Plan moodCode :Definition statusCode :New activity_time : Any Review -Oncology Journal code code code code :External Requirements Review ± JCAHO :Internal Policies Review ± Educational Plans :Other Organization Review ± American Cancer Society Reads: 1) Literature review done to collect current education research & best practices around breast cancer education. include in plan or No. & existing educational materials 4) Research patient education materials prepared by other organizations like the American Cancer Society. Oncology Nursing Society or 3rd 32 party payers. Participation typeCode :Target moodCode moodCode :Event statusCode :Event statusCode moodCode moodCode :Event :Event :Completed activity_time :Completed activity_time statusCode statusCode :Completed :Completed activity_time activity_time Role code Caregiver :Any value: Yes. in plan or No.

Findings: Four Perspectives     Methodology used Implications for HL7 RIM HL7 RIM implications for terminology modeling and domain terminologies General terminology implications Nursing Terminology Summit 2002 Report to AMIA 33 .

RIM understanding. and systems expertise Reliable and reproducible process. except:  HL7 RIM itself has been a moving target  Evolving and complex HL7 RIM attributes and vocabulary Nursing Terminology Summit 2002 Report to AMIA 34 .Findings: Methodology    Effective in helping the group evaluate ability of the HL7 RIM to represent the data related to breast cancer education  Modified instance diagrams were easy to learn and read Required nursing domain knowledge.

aggregate analysis activities (act.method_cd) ‡ Expand Act classes to include indirect care.type_cd) ‡ Expand observation methods (observation.class_cd) Nursing Terminology Summit 2002 Report to AMIA 35 .Findings: Implications for the RIM    Structurally accommodates breast cancer education use cases Add ³percent complete´ as new attribute within Act Enhance RIM vocabulary value sets to better cover nursing ‡ Expand role types beyond ³nurse´ (role. administrative.

subclasses. and registers vocabularies as candidates to populate the RIM Nursing Terminology Summit 2002 Report to AMIA 36 .Findings: HL7 RIM Implications for Terminology Modeling and Domain Terminologies  Terminologies cannot be freestanding must adhere to the rules of information model structure ‡ Vocabularies are expressed within classes. approves. and attributes ‡ HL7 data types exist for each attribute ‡ Data types are populated by published vocabularies and other value sets ‡ HL7 reviews.

Findings: HL7 RIM Implications for Terminology Modeling and Domain Terminologies  Symmetry between definition and execution ‡ Information model simply changes ³mood´ ‡ Terminology structure must accommodate the symmetry of the information model. and should have a similar ³mood´ concept Nursing Terminology Summit 2002 Report to AMIA 37 .

Findings: Terminology Implications  Intellectual content of existing nursing terminologies is robust. but structure not sufficient to meet interoperability standards ‡ Terms for many of the concepts exist ‡ In some instances terms are too general ‡ Semantic and syntactic relationships between terms are not defined ‡ Reinforces the Summit work to define reference terminology model for nursing Nursing Terminology Summit 2002 Report to AMIA 38 .

Next Steps (1) Model other general categories of nursing interventions (meta interventions).  Nursing Terminology Summit 2002 Report to AMIA 39 .  Develop a framework for how existing nursing terminologies fit into these models. and the HL7 RIM.  Consider use of methodology for nursing diagnoses and outcomes.

Next Steps (2)  Determine what data are essential to support the nursing process and to communicate with other stakeholders in patient care What data need to be collected and communicated  What level of granularity is appropriate  Nursing Terminology Summit 2002 Report to AMIA 40 .

An Information Model of the Nursing Process William Goossen Nursing Terminology Summit 2002 Report to AMIA 41 .

Purpose:  To report on the work of the Summit working group that dealt with  the HL7 RIM model of the nursing process and  templates for the Braden Scale for risk of pressure ulcer. Nursing Terminology Summit 2002 Report to AMIA 42 .

terms. and information and builds upon Harris¶s and Helleman¶s work. Create a template for one aspect of the nursing process. Relate the classes to one other.   that includes knowledge.   µClone¶ the classes under new names to represent relevant parts of the nursing process. Nursing Terminology Summit 2002 Report to AMIA 43 .   Explain the information model of the nursing process.Nursing process model  Find the appropriate classes in the RIM. a specific observation.

Nursing process model   Ongoing work: Corrected error in mixing process and structure: making two separate models   Activity Diagram of nursing process Class Diagram of information used in the nursing process. Nursing Terminology Summit 2002 Report to AMIA 44 .

n Define activities 1 .n 2002 Report to AMIA 45 .n Nursing Terminology Summit Implement care 1.n End care process [N] Make observation 1-n More (meta-) [Y] [Y] observations needed? [N] Set expected outcomes 1 .Start care process Activity Diagram of nursing process [Y] More observations needed? [N] Make meta-observation 1-n Need for care? [Y] Define diagnoses 1.

but not worked out.Class model of the Nursing Process findings:Observation leads to are based on clinical thinking relationship inferences:Observation gives as result clinical judgement relationship are determined from diagnosis:Observation suggests goal determination to solve problem relationship tries to solve gives focus to plan to reach the goals relationship tries to achieve planned_interventions:Procedure -Mood requires Assumed in model. implementation_of_care:Procedure describes care what is done and effects relationship -Mood need to have description of are goals met relationship Assumed in Model and worked out. goal:Observation to be found in outcomes:Observation Nursing Terminology Summit 2002 Report to AMIA 46 .

Issues      Can RIM be used to model process? Specializations: add distinctive attributes More clarity on nursing process as delivery mechanism and nursing process as documentation Discuss relation with CEN 13606 Justify approach / consistency check / validation Nursing Terminology Summit 2002 Report to AMIA 47 .

From the Models to Reference Terminology Nursing Terminology Summit 2002 Report to AMIA 48 .

Representing Nursing Concepts and Relationships in SNOMED CT Deb Konicek Nursing Terminology Summit 2002 Report to AMIA 49 .

SNOMED Convergent Terminology Group for Nursing  Composed of members having expertise in: -terminology development -creation and evaluation of terminology models for nursing concepts -the dissection (modeling) of nursing terms using a specific terminology model Nursing Terminology Summit 2002 Report to AMIA 50 .

and goals/outcomes concepts Nursing Terminology Summit 2002 Report to AMIA 51 .SNOMED CT Nursing Integration Efforts  Committed to: -utilizing existing nursing terminologies as source of nursing content -actively participating in standards work -striving for consistency with existing models -evaluating the usefulness of proposed ISO model for SNOMED CT integration of nursing diagnostic. intervention.

Findings Reference Terminology Model Dimension Subject of Information Subject of Information Focus Interprets Value Site Finding Site Method Method & Scales Nursing Terminology Summit 2002 Report to AMIA 52 .

Nursing Diagnosis Reference Terminology Model Dimension Subject of Information Subject of Information Focus Interprets Judgment Has interpretation Site Finding site Nursing Terminology Summit 2002 Report to AMIA 53 .

ISO Nursing Diagnosis Model NANDA ± Ineffective Individual Coping Has focus COPING Interprets:Ability to cope Has judgment INEFFECTIVE (interpretation) Has potentiality ACTUAL (context-qualifier) Has subject of information INDIVIDUAL(soi) Other components are not applicable Nursing Terminology Summit 2002 Report to AMIA 54 .

ISO Nursing Intervention Model Action Root procedure Target Has focus Site Procedure Site Route Approach Subject of care Means Using Recipient of care Nursing Terminology Summit 2002 Report to AMIA 55 .

components necessary for modeling nursing diagnoses & interventions were proposed/accepted by SNOMED Editorial Board -ISO model provides validation of these efforts -ISO diagnoses & Vocabulary Summit finding models provide future direction for nursing outcomes modeling initiatives Nursing Terminology Summit 2002 Report to AMIA 56 .attributes.SNOMED CT Nursing: Conclusion  Currently: -the discussed links.

From Reference Terminology to Terminology Systems Nursing Terminology Summit 2002 Report to AMIA 57 .

McKesson.Reference Terminology and the Next Generation of Systems: Advances at Cerner. and Siemens Pat Button Nursing Terminology Summit 2002 Report to AMIA 58 .

 Valuable forum for networking and addressing key issues that have challenged industry for many years.  Nursing Terminology Summit 2002 Report to AMIA 59 .  Providing significant impact within industry and standards organizations. positive effort.Overall Industry Sponsor Perspective  Nursing Terminology Summit is: Worthwhile.

 Nursing Terminology Summit 2002 Report to AMIA 60 .  Build knowledge-rich applications using a solid foundation.  Support communication within our clinical product line.McKesson: Horizon Clinicals  Clinical reference terminology strategy: Reduce customer build times.  Share common tools and core knowledge sets.

International Classification of Nursing Practice. NOC. NIC. etc.  Nursing Terminology Summit 2002 Report to AMIA 61 .McKesson:Horizon Clinicals  Clinical reference terminology foundation: SNOMED CT as a core reference terminology  LOINC  Evaluation of nursing vocabularies for inclusion: NANDA.

 Nursing Terminology Summit 2002 Report to AMIA 62 . terminology models.Siemens: Summit Impact Improved data representation for nursing concepts through integration of nursing terminology learnings into database design. middle tier architecture.  Consolidation of existing nursing terminologies into a unifying reference terminology model. & flexible end user interfaces.

& promote the work of the Terminology Summit in the healthcare market.Siemens: Summit Impact Engendered increased understanding of strategic needs & issues surrounding the implementation of a broader clinical terminology solution.  Leveraged opportunities to communicate. educate.  Nursing Terminology Summit 2002 Report to AMIA 63 .

Provision of evidence based. .Cerner Strategy  Strategy:   Cerner¶s Information ModelTM ± Controlled medical terminology. Executable KnowledgeTM Nursing Terminology Summit 2002 Report to AMIA 64 . executable knowledge that leverages the Information ModelTM architecture and structures.

Cerner Information Model TM ‡ The Information ModelTM is structured in a manner that can house specific terminology sets and inter-relate them. 2002 Report to AMIA 65 . and Cerner clients to manage their own nomenclature Nursing Terminology Summit extensions. ‡ HLi is Cerner¶s business partner. as well as provide the flexibility to accommodate local extensions and preferences for synonyms. HLi provides the meta database and modeling tools to enable Cerner to manage third party terminologies.

Cerner Information Model TM ‡ Information ModelTM based on SNOMED CT. Nursing Terminology Summit 2002 Report to AMIA 66 . including being one of two parties in a pilot program to test a new terms submissions and request management process. Cerner & SNOMED International have a close working relationship. ‡ Nursing terminologies from a CMT perspective refers to a set of terminologies for the nursing care process.

Nursing Terminology Summit 2002 Report to AMIA 67 . pathways. the Cerner Information Model. is based on SNOMED CT and leverages the mapping SNOMED has completed to various terms from the nursing languages. Cerner¶s infrastructure.Cerner Approach: Nursing Terminologies  Key Points:     Cerner does not endorse any one or several of the ANA recognized nursing languages. Current focus: definition of model for all patient care orders/interventions & outcomes. clinical diagnoses and problems to provide basis for integration of SNOMED CT and definition of data elements to use in order sets. Cerner will provide the infrastructure to support the use of any of the ANA recognized nursing languages. plans of care.

Direct Use of Formal Terminology Systems in Clinical Applications: Difficulties and Solutions Suzanne Bakken and Nicholas Hardiker Nursing Terminology Summit 2002 Report to AMIA 68 .

Aims (and assumptions)  To consider the direct use of formal terminology systems in clinical applications  Formal terminology systems can play both a reference role AND an interface role  To expose difficulties and inform the development of solutions  µPlug and play¶ is not possible Nursing Terminology Summit 2002 Report to AMIA 69 .

‡ they must behave in a rigorously predictable way  «and the needs of users ‡ they must be understandable.. usable and fit with routine practice Nursing Terminology Summit 2002 Report to AMIA 70 ..Difficulties  Direct use is awkward  There is a conflict between the characteristics of formal terminology systems.

in line with routine practice.Storyboarding µA nurse assesses the nutritional status of a patient in order to make a diagnosis¶  Any proposed application should support this process while allowing the nurse to document the assessment. via a formal terminology system  Nursing Terminology Summit 2002 Report to AMIA 71 .Methods .

Methods .Use case analysis A System Present relevant item for selection Nurse Nursing Terminology Summit 2002 Report to AMIA 72 .

Methods - Scenario development
The application presents a list of relevant assessment topics, including µNutritional assessment¶ The application presents through a data entry form a number of relevant sub-topics such as µMobility¶ etc
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Methods - Prototyping
A system

Nutritional assessment
Appearance Underweight Mobility Weight Diagnosis
Mobile Overweight Immobile

kg
Nutrition Nutrition

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Methods - Activity diagramming
User Interface Dialogue Terminology

Select topic

Return topic

Get relevant item Put relevant item on form

Return relevant item

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the dialogue sub-system and the formal terminology system .each will impact the others Nursing Terminology Summit 2002 Report to AMIA 76 .Key findings   It is difficult to capture the pragmatics of routine practice within formal terminology systems A dialogue sub-system is needed to manage the things traditionally embedded within interface terminologies   clinical knowledge business rules  There will be a dependency between the user interface.

Messages to Take Home     Much has been done to develop and integrate nursing terminology standards. Evaluation and progress are iterative and ongoing. Draft standards and other insights are already being used to develop tomorrow¶s applications. Much remains to be done. Nursing Terminology Summit 2002 Report to AMIA 77 .

Thank you!  Questions or comments? Nursing Terminology Summit 2002 Report to AMIA 78 .