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Computer Systems for Healthcare Services(CSH7105) 10 The Role of Standardized Terminology and Language in Informatics Learning Outcomes 1. Understand what standardized healthcare terminology is and why it is important to nursing. 2. Describe the American Nurses Association (ANA) recognition criteria established for recognizing standardized terminologies. Learning Outcomes 3. Describe each of the ANA recognized terminologies and the benefits of use when implemented within an electronic healthcare record. 4. Discuss standardized terminologies used for the different parts of the nursing process and their similarities and differences. Learning Outcomes 5. Define the different types of terminology structures, such as a classification system (e.g. NANDA, NIC, NOC) versus a reference terminology (ICNP, SNOMED-CT). 6. Demonstrate how standard terminologies facilitate the use of evidence-based practice and decision-support rules. Learning Outcomes 7. Illustrate how using standardized healthcare terminologies correlates to the U.S. meaningful use criteria. 8. Identify the benefits of using structured terminologies within electronic healthcare records. Standardized Terminology • Structured and controlled languages that have been developed and approved by an authoritative body Healthcare Terminology Standards • Designed to enable and support widespread interoperability and for the purpose of sharing information • Essential to the widespread implementation of EHRs Meaningful Use • The goal is to exchange clinical structured data in a manner that is accurate and complete to improve client care in a cost-efficient way. Terminology Definitions • Concepts • Codes • Clinical terminology-enables the capture of data at the level of detail necessary for patient care documentation and is used to describe health conditions Terminology and Nursing • Need a standardized nursing language that is common to all nurses Languages and Classifications • Billing codes set by HIPAA • International Classification of Disease (ICD) developed by World Health Organization • Current Procedural Terminology (CPT) developed by American Medical Association Clinical Terminology • Unified Medical Language System (UMLS) developed by National Library of Medicine Clinical Terminology • American Nurses Association recognizes terminology for use by nurses – Clinical Care Classification (CCC) – North American Nursing Diagnosis Association International (NANDA-I) – Nursing Intervention Classification (NIC) – Nursing Outcome Classification (NOC) – Omaha System – SNOMED CT SNOWMED CT • Globally recognized terminology • Promotes evidence-based practice • Undergoes review process to keep up to date LOINC • Logical Observation Identifiers, Names, and Codes • Laboratory and clinician observations terminology • Nursing content found in one domain Clinical Care Classification System • Design based on six steps of nursing process • 182 diagnostic concepts • Subcategories represent interventions, procedures, treatments, and activities International Classification of Nursing Practice • Contains diagnoses, actions, and outcomes TABLE 15–9 ICNP Axes With Examples NANDA International • Was the first nursing terminology recognized by ANA • Can be actual or potential health problem • Contains nursing diagnoses defined by signs and symptoms Nursing Interventions Classifications • Describe interventions used in nursing care • Seven domains of interventions • Can be used in an electronic health record Nursing Outcomes Classifications • Describe outcomes related to nursing interventions • Seven domains of outcomes • Can be used in an electronic health record Omaha System • Research-based taxonomy • Assessment component—Problem Classification Scheme • Intervention component— Intervention Scheme • Outcomes component—Problem Rating Scale for Outcomes PeriOperative Nursing Data Set • Developed by Association of periOperative Registered Nurses (AORN) • Composed of nursing diagnoses, interventions, and outcomes Benefits of Implementation • Client-specific benefits – Decreased costs – Increased quality – Improved outcomes – Improved safety Benefits of Implementation • Provider/Nursing Benefits – Complete access to data – Increased efficiency – Increased accuracy – Increased effectiveness – Improvement in client care Benefits of Implementation • Organizational – Decreased costs – Decision support – Outcome measurement – Data mining Future Directions • Clinical Observations Recording and Encoding (CORE) developed by National Library of Medicine will be used. • Health information technology will increase communication between provider and client.