Nursing Terminology Summit

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

Overview of the Summit

The Nursing Terminology Summit Annual meetings since 1999 Participants from 5 continents Diverse expertise and work settings

Summit Steering Committee Judy Ozbolt, Chair Ida Androwich Suzanne Bakken Patricia Button Nicholas Hardiker Charles Mead Judith Warren Christine Zingo

Summit Sponsors NLM HRSA AMA AMIA* Cerner* HIMSS

IDX 3M McKesson* Siemens* SNOMED*

*Sponsor in 2002

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

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)

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

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

Development, Evaluation, and Use of Reference Terminology:

The Big Picture

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

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

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.

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

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.

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

Developing and Evaluating the Models

Progress at the Summit,1999-2002

A Domain Concept Model for Findings:

Similarities and Differences among Diagnoses, Goals, and Outcomes

Judith J. Warren

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

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

Findings Reference Terminology Model

MethodDerivation

Dimension

Subject of Information Focus

Nursing Diagnosis Reference Terminology Model

Dimension

Judgment

Terminology and Information Models for

Nursing Actions:

The Use-Case Approach to Development and Testing

Pat Button

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.

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

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)

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

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.

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.

Use Case 1 - Research to Define Best Plan

: Breast CancerEducation Plan

moodCode:DefinitionstatusCode:Newactivity_time: Any

Procedure

value:Yes, include in plan or No,do not include

: LiteratureReview -- OncologyJournal moodCode

:Event

statusCode

:Completedactivity_time

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

typeCode:Author

Participation

code:Committee

:External RequirementsReview – JCAHOmoodCode

:Event

statusCode

Repeated for each review source for inclusion in the education plan

Repeated for each review source for inclusion in the education planObservation Observation

:InternalPoliciesReview – EducationalPlansmoodCode

:Event

statusCode

Observation

:Other OrganizationReview – American Cancer SocietymoodCode

:Event

statusCode

Observation

Evaluates EvaluatesEvaluates

Findings: Four Perspectives Methodology used Implications for HL7 RIM HL7 RIM implications for terminology

modeling and domain terminologies General terminology implications

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

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)

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

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

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

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.

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

An Information Model of the Nursing Process

William Goossen

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 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.

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.

Start care process

Set expected outcomes 1 - n

Make observation 1-n

Make meta-observation 1-n

More observations

needed?

Need for

Define activities 1 - n

Implement care 1- n

[N]More (meta-)

observationsneeded?

Define diagnoses 1- n

[Y][N]

End care process

Activity Diagram of nursing process

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

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

From the Models to Reference Terminology

Representing Nursing Concepts and Relationships

in SNOMED CT

Deb Konicek

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

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

Findings Reference Terminology Model

Method

Dimension

InterpretsSubject ofInformation

Finding Site Method & Scales

Nursing Diagnosis Reference Terminology Model

Dimension

JudgmentInterprets Has

interpretation

Finding site

Subject ofInformation

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

ISO Nursing Intervention Model

Action

Target

Subject of care

Root procedure

Has focus

Recipient of care

Procedure Site

Approach

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

From Reference Terminology to

Terminology Systems

Reference Terminology and the Next Generation of

Systems:

Advances at Cerner, McKesson, and Siemens

Pat Button

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.

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.

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.

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.

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.

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.

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.

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.

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.

Direct Use of Formal Terminology Systems in

Clinical Applications:

Difficulties and Solutions

Suzanne Bakken and Nicholas Hardiker

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

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

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

Methods - Use case analysis

A System

Present relevantitem for selection

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

Methods - PrototypingA system

Nutritional assessment

UnderweightAppearance

Mobility

Weight kg

Overweight

Mobile Immobile

Diagnosis Nutrition Nutrition

Methods - Activity diagramming

User Interface Dialogue Terminology

Select topicReturn topic Get relevant

itemReturn relevant

Put relevantitem on form

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

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.

Thank you! Questions or comments?

Nursing Terminology Summit

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