lecture 5 standardized terminology and language in health care (chapter 15)

http://www.csun.edu/~dn58412/IS531/IS531_SP15.html

Lecture 5Standardized Terminology and

Language in Health Care(Chapter 15)

Learning ObjectivesLearning 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

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Standardized TerminologyStandardized 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

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Healthcare Terminology Healthcare Terminology StandardsStandards

• 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 cost-efficiency in client care

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Terminology Definitions . . .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 structure-relationship

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. . .Terminology Definitions. . .Terminology Definitions• Reference Terminology: a set of concepts

with definitional relationship– To retrieve data across healthcare

settings, domains, 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

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Types of Healthcare Types of Healthcare TerminologiesTerminologies

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Technology Development Technology Development GuidelinesGuidelines

Terminology and NursingTerminology 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, and outcomes

• To support interoperability, sharing comparable data with other healthcare organizations

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Languages and Languages and Classifications . . .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

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ICD ExamplesICD Examples

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CPT ExamplesCPT Examples

Languages and Languages and Classifications . . .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, and Codes (LOINC)

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SNOMED-CTSNOMED-CT

• Globally recognized terminology (concepts, descriptions, 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. p.305)• Using parent-child relationship to build

vertical hierarchies

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SNOMED-CT ExampleSNOMED-CT Example

LOINCLOINC

• “Logical Observation Identifiers, Names, and Codes”

• Terminologies for laboratory and clinical observations

• For recording a single observation, measurement, test result.

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LOINC ExamplesLOINC Examples

Languages and Languages and Classifications . . .Classifications . . .

• 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)

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Clinical Care Classification Clinical Care Classification (CCC) System(CCC) System

• To facilitate patient care documentation at the point of care

• CCC of nursing diagnosis and outcome:– 182 diagnosis concepts in categories and sub-

categories; 3 outcome qualifiers.

• CCC for nursing intervention: – 198 concepts in categories and sub-categories

to represent interventions, procedures, treatments, and activities.

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International Classification International Classification of Nursing Practice (ICNP)of Nursing Practice (ICNP)

• For point-of-care and reference terminology

• Contains diagnoses, actions, and outcomes in 7 axes (dimensions)

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ICNP ExamplesICNP Examples

NANDA-INANDA-I

• “North American Nursing Diagnosis International”

• Each nursing diagnosis actual or potential health problem has: description, definition, defining characteristics (manifestations, signs, symptoms)

• 13 domains , 7 axes(dimensions)

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NANDA DomainsNANDA Domains

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NANDA-I ExamplesNANDA-I Examples

Nursing Interventions Nursing Interventions Classification (NIC)Classification (NIC)

• Describe interventions used in nursing care

• 30 classes, 7 domains and 542 interventions

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NIC DomainsNIC Domains

Nursing Outcomes Nursing Outcomes Classification (NOC)Classification (NOC)

• Describe outcomes related to nursing interventions

• 31 classes and 7 domains of outcomes • Each outcome has: definition, measurement

scale, associated indicators, supporting references

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NOC DomainsNOC Domains

Omaha SystemOmaha 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

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Omaha SystemsOmaha Systems

Perioperative Nursing Data Perioperative Nursing Data (PNDS) Set(PNDS) Set

• Provide wording and definitions for nursing diagnoses, interventions, and outcomes

• Allow collection data in a uniform way for analyses

• 4 components, 75 diagnoses, 135 interventions, and 27 nurse-sensitive patient care outcomes

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PNDS ExamplePNDS Example

Benefits of ImplementationBenefits of Implementation

• Client-specific benefits– Decreased costs– Increased quality– Improved outcomes– Improved safety

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Benefits of ImplementationBenefits of Implementation

• Provider/Nursing Benefits– Complete access to data– Increased efficiency– Increased accuracy– Increased effectiveness– Improvement in client care

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Benefits of ImplementationBenefits of Implementation

• Organizational Benefits– Decreased costs– Decision support– Outcome measurement– Data mining

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Issues and ConcernsIssues and Concerns

• Integrate systems with locally defined concepts, 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

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Nursing Assessment Nursing Assessment ExamplesExamples

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Nursing Diagnosis/Problem Nursing Diagnosis/Problem ExamplesExamples

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Nursing Intervention ExamplesNursing Intervention Examples

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Nursing Goal/Potential Nursing Goal/Potential Outcome ExamplesOutcome Examples