Minnesota Recommendation to Use of a

Standard Nursing Terminology in All Health Care Settings

Bonnie L. Associate Professor & Director Center for Nursing Informatics, University of Minnesota, School of Nursing

2

Vision for Nursing Data in an Electronic Health Record Supported Clinical Data Warehouse

Continuum of Care

Nursing

Clinicians

Students/Faculty

Researchers

Practice

Evaluation &

Quality

Health Policy

Professional organizations

3

Westra, B.L., Delaney, C.W., Konicek, D., & Keenan, G. (2008). Nursing Standards to Support the Electronic Health Record. Nursing Outlook, 56, 258-266.e1

4

Use of Nursing Terminologies

• Data Sets – Big Picture

• User Interface

• Health Information Exchange

5

NMDS NMMDS (clinical) (management)

• Patient Demographics– Date of birth– Race/ Ethnicity

• Nursing Care Elements– Nursing Dx– Interventions– Outcomes

• Service Elements– Unique Number of

Principal Registered Nurse Provider

– Discharge or Termination Date *

• Environment– Type of nursing delivery

unit/service – Method of care delivery

• Nursing Care Resources – Management

demographic profile – Staffing

• Financial Resources – Payer type – Reimbursement

User Interface Terminologies

• NNN– NANDA - North American Nursing Diagnosis Association – NIC - Nursing Interventions Classification System– NOC Nursing Outcomes Classification System

• CCC - Clinical Care Classification• ICNP - International Classification of Nursing

Practice• Omaha System• PNDS - Perioperative Nursing Data Set

6

7

Health Information Exchange

• Logical Observation Identifier Names & Codes (LOINC®) – Assessments

• Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT)– Diagnoses/ Problems– Interventions– Outcomes

INTEROPERABILITY

Minnesota e-Health InitiativeA public-private collaboration established in 2004Legislatively charteredCoordinates and recommends statewide policy on e-HealthDevelops and acts on statewide e-health priorities Reflects the health community’s strong commitment to act in a coordinated, systematic and focused way

9

“Vision: … accelerate the adoption and effective use of Health Information Technology to improve healthcare quality, increase patient safety, reduce healthcare costs, and enable individuals and communities to make the best possible health decisions.”

Minnesota Recommendation

1.All health and health care settings should create a plan for implementing an (ANA) recognized terminology within their (EHR).

2.Each health and health care setting type should achieve consensus

3.Education should be provided and guidance be developed for selecting the terminology

Minnesota Recommendation

1.When exchanging a Consolidated Clinical Document Architecture (C-CDA) document with another setting for problems and care plans, ise SNOMED-CT and LOINC

2.The Omaha System be used for exchange between public health or community-based settings if both use the same terminology

Next

• Dr. Karen Monsen will report on the current state of nursing terminology implementation

• Break into groups and brainstorm 3 actions to achieve the recommendation

• Report back