nursing terminology summit
TRANSCRIPT
Nursing Terminology Summit 2002 Report to AMIA 1
Development, Evaluation, and Use of Reference
Terminology for Nursing
Progress Report from the Nursing Terminology Summit
Nursing Terminology Summit 2002 Report to AMIA2
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 AMIA4
The Nursing Terminology Summit Annual meetings since 1999 Participants from 5 continents Diverse expertise and work settings
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Summit Steering Committee Judy Ozbolt, Chair Ida Androwich Suzanne Bakken Patricia Button Nicholas Hardiker Charles Mead Judith Warren Christine Zingo
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Summit Sponsors NLM HRSA AMA AMIA* Cerner* HIMSS
IDX 3M McKesson* Siemens* SNOMED*
*Sponsor in 2002
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Mission of the Nursing Terminology Summit Promote and support
the development, evaluation, and use of reference terminology for nursing and
the integration of reference nursing terminology with healthcare applications and with other healthcare terminological systems
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The Summit’s Methods of Work Annual meeting Intervening collaboration Think tank for resolving questions,
coordinating, setting directions for development to be done elsewhere
Worldwide scope Expert authority (no formal
authority)
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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, evaluate, integrate, and use reference terminology for nursing
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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, LOINC Nursing terminology models submitted to
ISO committee in 2002; now a Draft Standard
Use of terminology models to guide development of terminology in SNOMED and elsewhere
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Development, Evaluation, and Use of Reference Terminology:
The Big Picture
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Key Definitions (ISO CD 17115) Domain Concept Model: set of formal
categories, semantic links, 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 AMIA13
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
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Development of Reference Terminology for Nursing Goal:
Populate models with words representing instances of the concepts.
Methods: Dissect terms from nursing classifications and
other vocabularies according to models to create formal representations.
Create controlled vocabularies from common expressions and dissect those expressions.
Integrate formal representations from many sources within standards developing organizations.
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Evaluation of Reference Terminology for Nursing Iterative and continual Test and retest models, expressions,
and conceptualizations Must lead to coherent and growing
body of knowledge
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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, and clarify operations and transactions.
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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 terminologies
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Developing and Evaluating the Models
Progress at the Summit,1999-2002
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A Domain Concept Model for Findings:
Similarities and Differences among Diagnoses, Goals, and Outcomes
Judith J. Warren
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Findings, Outcomes, and Goals
Findings (observation)
O1A O2A
Outcome O1A X O2A
Goal X OE
Goal Variance
X OE-O2A
O=observation, X=intervention, A=actual, E=expected
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Conclusions Goal is no different from Finding in
the terminology model, but in the information model Goal differs in timing and mood
Outcome is no different from Finding in the terminology model, but in the information model Outcome has links to the baseline value and to the Intervention
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Findings Reference Terminology Model
Value
MethodDerivation
Dimension
Subject of Information Focus
Site
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Nursing Diagnosis Reference Terminology Model
Dimension
Subject of Information Focus
Site
Judgment
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Terminology and Information Models for
Nursing Actions:
The Use-Case Approach to Development and Testing
Pat Button
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Summit Interventions Group Group has focused on nursing
interventions since initial Summit meeting in 1999.
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), from both terminological and structural perspectives.
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Goal of the Intervention Team
Ensure that the HL7 RIM supports nursing terminology and that it provides a foundation for integrating nursing intervention concepts.
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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
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Approach
Analyze a random selection of interventions from existing classification systems for fit with HL7 RIM
Selected “Patient Education” as intervention for further action (e.g. use case development)
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Approach Created high level education Use Cases
(N=6) Validated Education Use Cases based
on expert/group feedback Used Nine-Step Model (Russler, 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
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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.
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Use Case 1 - Develop Education Plan
Sequence:1. A literature review is performed to collect current education research and best practices.2. Research external requirements from organizations like JCAHO, HCFA, FDA, NCI, and
large volume 3rd party payers.3. Collect internal policies, requirements, and existing educational materials4. Research patient education materials prepared by other organizations like the American
Cancer Society, Oncology Nursing Society or 3rd party payers.5. Gain agreement if standard terminology will be used.6. Draft initial template for educational interventions. Include the intervention,
method, responsibility, intensity, measurement criteria and an example of expected outcome.
7. Iterative review process with team members.8. Evaluate compliance with standards.9. Agreement on final educational plan10. Link finalized education plan to problem list11. Provide links from standard plan to education knowledge bases. The links should be
context specific.12. Review and modify on a regular basis.
Pre conditions:• Breast cancer patients were chosen for the first education standard.• An oncology education standards committee was formed• Members include Chief Oncologist, VP of nursing, VP of ancillary services, Advanced Practice Nurses, Director
of the Oncology clinic, manager of the oncology inpatient floor, Director of OR services, Manager of oncology homecare services, Clinical Pharmacists.
Post conditions:• Add to repository of education plans.
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Use Case 1 - Research to Define Best Plan
code
: Breast CancerEducation Plan
moodCode:DefinitionstatusCode:Newactivity_time: Any
Procedure
value:Yes, include in plan or No,do not include
code
: LiteratureReview -- OncologyJournal moodCode
:Event
statusCode
:Completedactivity_time
:Any
Evaluates
Reads:1) Literature review done to
collect current education research & best practices around breast cancer education.
2) Research external requirements: JCAHO, HCFA, FDA, NCI, & large volume 3rd party payers.
3)Collect internal policies, requirements, & existing educational materials
4) Research patient education materials prepared by other organizations like the American Cancer Society, Oncology Nursing Society or 3rd party payers.
typeCode:Target
Participation
codeCaregiver
Role
typeCode:Author
Participation
code:Committee
Role
value:Yes, include in plan or No,do not include
code
:External RequirementsReview – JCAHOmoodCode
:Event
statusCode
:Completedactivity_time
:Any
Repeated for each review source for inclusion in the education plan
Repeated for each review source for inclusion in the education planObservation Observation
code
:InternalPoliciesReview – EducationalPlansmoodCode
:Event
statusCode
:Completedactivity_time
:Any
Observation
value:Yes, include in plan or No,do not include
code
:Other OrganizationReview – American Cancer SocietymoodCode
:Event
statusCode
:Completedactivity_time
:Any
Observation
value:Yes, include in plan or No,do not include
Evaluates EvaluatesEvaluates
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Findings: Four Perspectives Methodology used Implications for HL7 RIM HL7 RIM implications for terminology
modeling and domain terminologies General terminology implications
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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, 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
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Findings: Implications for the RIM
Structurally accommodates breast cancer education use cases
Add “percent complete” as new attribute within Act
Enhance RIM vocabulary value sets to better cover nursing• Expand role types beyond “nurse” (role.type_cd)• Expand observation methods
(observation.method_cd)• Expand Act classes to include indirect care,
administrative, aggregate analysis activities (act.class_cd)
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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,
subclasses, and attributes• HL7 data types exist for each attribute• Data types are populated by published
vocabularies and other value sets• HL7 reviews, approves, and registers
vocabularies as candidates to populate the RIM
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Findings: HL7 RIM Implications for Terminology Modeling and Domain Terminologies
Symmetry between definition and execution• Information model simply changes “mood”• Terminology structure must accommodate
the symmetry of the information model, and should have a similar “mood” concept
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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
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Next Steps (1) Model other general categories of
nursing interventions (meta interventions).
Consider use of methodology for nursing diagnoses and outcomes.
Develop a framework for how existing nursing terminologies fit into these models, and the HL7 RIM.
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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
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An Information Model of the Nursing Process
William Goossen
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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.
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Nursing process model Find the appropriate classes in the RIM.
‘Clone’ the classes under new names to represent relevant parts of the nursing process.
Relate the classes to one other. Explain the information model of the
nursing process. Create a template for one aspect of the
nursing process, a specific observation, that includes knowledge, terms, and
information and builds upon Harris’s and Helleman’s work.
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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.
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Start care process
Set expected outcomes 1 - n
Make observation 1-n
Make meta-observation 1-n
More observations
needed?
Need for
care?
Define activities 1 - n
Implement care 1- n
[Y]
[N]More (meta-)
observationsneeded?
[Y]
[N]
[Y]
Define diagnoses 1- n
[Y][N]
End care process
Activity Diagram of nursing process
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Class model of the Nursing Process
outcomes:Observation
findings:Observation inferences:Observation
diagnosis:Observation
goal:Observation
planned_interventions:Procedure -Mood
implementation_of_care:Procedure -Mood
Assumed in model, but not worked out.
Assumed in Model and worked out.
clinical thinking relationship leads to are based on
clinical judgement relationship
gives as result
are determined from
goal determination to solve problem relationship
suggests
tries to solve
plan to reach the goals relationship
gives focus to
tries to achieve what is done and effects relationship
requires
describes care
are goals met relationship
need to have description of
to be found in
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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
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Representing Nursing Concepts and Relationships
in SNOMED CT
Deb Konicek
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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
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SNOMED CTNursing 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,and goals/outcomes concepts
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Findings Reference Terminology Model
Value
Method
Dimension
Subject of Information Focus
Site
InterpretsSubject ofInformation
Finding Site Method & Scales
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Nursing Diagnosis Reference Terminology Model
Dimension
Subject of Information Focus
Site
JudgmentInterprets Has
interpretation
Finding site
Subject ofInformation
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ISO Nursing Diagnosis Model
NANDA – Ineffective Individual CopingHas focus COPING Interprets:Ability to copeHas judgment INEFFECTIVE (interpretation)Has potentiality ACTUAL (context-qualifier) Has subject of information INDIVIDUAL(soi)Other components are not applicable
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ISO Nursing Intervention Model
Action
Site
Route
Using
Means
Target
Subject of care
Root procedure
Has focus
Recipient of care
Procedure Site
Approach
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SNOMED CT Nursing: Conclusion
Currently: -the discussed links,attributes,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
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Reference Terminology and the Next Generation of
Systems:
Advances at Cerner, McKesson, and Siemens
Pat Button
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Overall Industry Sponsor Perspective Nursing Terminology Summit is:
Worthwhile, positive effort. Providing significant impact within
industry and standards organizations. Valuable forum for networking and
addressing key issues that have challenged industry for many years.
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McKesson: Horizon Clinicals Clinical reference terminology
strategy: Reduce customer build times. Share common tools and core
knowledge sets. Build knowledge-rich applications using
a solid foundation. Support communication within our
clinical product line.
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McKesson:Horizon Clinicals Clinical reference terminology
foundation: SNOMED CT as a core reference
terminology LOINC Evaluation of nursing vocabularies for
inclusion: NANDA, NIC, NOC, International Classification of Nursing Practice, etc.
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Siemens: Summit Impact Improved data representation for
nursing concepts through integration of nursing terminology learnings into database design, middle tier architecture, terminology models, & flexible end user interfaces.
Consolidation of existing nursing terminologies into a unifying reference terminology model.
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Siemens: Summit Impact Engendered increased
understanding of strategic needs & issues surrounding the implementation of a broader clinical terminology solution.
Leveraged opportunities to communicate, educate, & promote the work of the Terminology Summit in the healthcare market.
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Cerner Strategy Strategy:
Cerner’s Information ModelTM – Controlled medical terminology.
Executable KnowledgeTM - Provision of evidence based, executable knowledge that leverages the Information ModelTM architecture and structures.
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Cerner Information ModelTM
• The Information ModelTM is structured in a manner that can house specific terminology sets and inter-relate them, as well as provide the flexibility to accommodate local extensions and preferences for synonyms.
• HLi is Cerner’s business partner. HLi provides the meta database and modeling tools to enable Cerner to manage third party terminologies, and Cerner clients to manage their own nomenclature extensions.
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Cerner Information ModelTM
• Information ModelTM based on SNOMED CT. Cerner & SNOMED International have a close working relationship, including being one of two parties in a pilot program to test a new terms submissions and request management process.
• Nursing terminologies from a CMT perspective refers to a set of terminologies for the nursing care process.
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Cerner Approach: Nursing Terminologies Key Points:
Cerner does not endorse any one or several of the ANA recognized nursing languages.
Cerner will provide the infrastructure to support the use of any of the ANA recognized nursing languages.
Cerner’s infrastructure, the Cerner Information Model, is based on SNOMED CT and leverages the mapping SNOMED has completed to various terms from the 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, pathways, plans of care.
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Direct Use of Formal Terminology Systems in
Clinical Applications:
Difficulties and Solutions
Suzanne Bakken and Nicholas Hardiker
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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 ‘Plug and play’ is not possible
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Difficulties Direct use is awkward
There is a conflict between the characteristics of formal terminology systems...• they must behave in a rigorously
predictable way …and the needs of users
• they must be understandable, usable and fit with routine practice
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Methods - Storyboarding ‘A 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, in line with routine practice, via a formal terminology system
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Methods - Use case analysis
A System
Present relevantitem for selection
Nurse
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Methods - Scenario development
The application presents a list of relevant assessment topics, including ‘Nutritional assessment’The application presents through a data entry form a number of relevant sub-topics such as ‘Mobility’etc
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Methods - PrototypingA system
Nutritional assessment
UnderweightAppearance
Mobility
Weight kg
Overweight
Mobile Immobile
Diagnosis Nutrition Nutrition
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Methods - Activity diagramming
User Interface Dialogue Terminology
Select topicReturn topic Get relevant
itemReturn relevant
item
Put relevantitem on form
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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, the dialogue sub-system and the formal terminology system - each will impact the others
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Messages to Take Home Much has been done to develop and
integrate nursing terminology standards. Much remains to be done. Evaluation and progress are iterative and
ongoing. Draft standards and other insights are
already being used to develop tomorrow’s applications.