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Lecture 5Standardized Terminology and
Language in Health Care(Chapter 15)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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