Big Data Plays a Vital Role in Healthcare Sector

Standard Nursing Terminologies: A Landscape Analysis MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726 May 15, 2017 Table of Contents I. Introduction …………………………………………………………………………………………. 4 II. Background ………………………………………………………………………………………….. 4 III. Landscape Analysis Approach ………………………………………………………………….. 6 IV. Summary of Background Data …………………………………………………………………. 7 V. Findings……………………………………………………………………………………………….. 8 A. Reference Terminologies ………………………………………………………………………………………..8 1. SNOMED CT………………………………………………………………………………………………………………….. 8 2. Logical Observation Identifiers Names and Codes (LOINC) ……………………………………………….. 10 B. Interface Terminologies ………………………………………………………………………………………. 11 1. Clinical Care Classification (CCC) System ………………………………………………………………………… 11 2. International Classification for Nursing Practice (ICNP) ……………………………………………………. 12 3. NANDA International (NANDA-I)……………………………………………………………………………………. 14 4. Nursing Interventions Classification System (NIC) and Nursing Outcomes 4. Classification (NOC) …………………………………………………………………………………………………….. 15 5. Omaha System ……………………………………………………………………………………………………………. 16 6. Perioperative Nursing Data Set (PNDS) ………………………………………………………………………….. 18 7. Alternative Billing Concepts (ABC) Codes ……………………………………………………………………….. 19 C. Minimum Data Sets ……………………………………………………………………………………………. 20 1. Nursing Minimum Data Set (NMDS) ………………………………………………………………………………. 20 2. Nursing Management Minimum Data Set (NMMDS) ……………………………………………………….. 22 VI. Health IT Developers – Perspective …………………………………………………………. 23 VII. Emerging Issues in Using SNTs ……………………………………………………………….. 24 1. Lack of Alignment on Terminology Standards for Nursing Content Definition …………………….. 24 2. Customized Development and Implementation of EHR Systems ……………………………………….. 24 3. Resource-Intensive Mapping Requirements, Curation and Maintenance …………………………… 24 4. Licensing Fees, Copyrights and Associated Pricing Challenges …………………………………………… 25 5. Incomplete Electronic Documentation of Nursing Care ……………………………………………………. 25 Identifying Challenges and Opportunities within Standard Nursing Terminologies 2 VIII. Conclusion …………………………………………………………………………………………. 26 Appendix A: Expanded Nursing Terminologies Timeline ……………………………………… 27 Appendix B: Pre-Determined Landscape Assessment Questionnaire …………………….. 34 Appendix C: EHR Developer Assessment Questionnaire ……………………………………… 35 Appendix D: List of Abbreviations …………………………………………………………………… 36 References ………………………………………………………………………………………………….. 38 Identifying Challenges and Opportunities within Standard Nursing Terminologies 3 I. Introduction With the rapid adoption of health IT and the promotion of interoperability to improve health, consistent standards and common data elements are the foundation for the advancement of care models. This advancement is based on objectives such as capturing sharable patient and care information across disciplines and care settings, enabling more accurate and less burdensome measurement of the quality of care delivered, and supporting ongoing research and analysis. Within this context, the nursing profession can contribute an enormous amount of valuable data related to the care of the patient and the nursing process. However, if nursing data are not stored in a standardized electronic format, or easily translated to a vocabulary used by interdisciplinary care team members, the value and contributions of nursing to patient outcomes may not be measurable or retrievable (Welton & Harper, Measuring Nursing Care Value, 2016). With more than 3.6 million members, nurses constitute the largest workforce in health care, and hospital-based nurses spend as much as 50 percent of their time in direct patient care (Hurst) (Nursing Fact Sheet, 2011) (McMenamin, 2016). As we move forward with innovative strategies to optimize the health of patients and communities, the omission of nursing data due to a lack of agreement on a standardization strategy would be unfortunate. To this end, the Office of the National Coordinator for Health IT (ONC) is working with MBL Technologies and Clinovations Government + Health, Inc. (Clinovations GovHealth) (hereafter the project team) to conduct a landscape assessment to better understand the current state and challenges associated with using terminologies and classifications to support nursing practice within health information technology (health IT) solutions. Through a literature review and interviews with terminology owners, this assessment examines the current state of development and usage within the 12 Standard Nursing Terminologies (SNT) recognized by the American Nurses Association (ANA). This report:    II. Defines a brief history of the development of standard nursing terminologies and efforts to gain consensus on a strategy for their use; Includes the level of advancement and interoperability of individual terminologies with electronic health records (EHRs); and Identifies themes in the form of challenges and opportunities. Background Nursing terminologies and vocabulary structures first developed in 1973, and many have changed significantly since their inceptions. Big Data Plays a Vital Role in Healthcare Sector

Realizing that the standardization of nursing care documentation was a critical component to support interoperable health information, the ANA in 1989 created a process to recognize languages, vocabularies and terminologies that support the nursing practice (ANA, 2015). Current action plans and guidelines, descending from the work of individuals such as James J. Cimino and organizations such as the National Committee on Vital and Health Statistics (NCVHS) and the ANA, continue to be refined (Cimino J. , 1998) (Cimino, Hripcsak, Johnson, & Clayton, 1989) (Sujansky, 2002). However, the inability to ensure the availability of sharable and comparable nursing data remains an issue. Increased focus on longitudinal and interdisciplinary documentation, care quality and value Identifying Challenges and Opportunities within Standard Nursing Terminologies 4 precipitates a need to accurately quantify the contribution of each care team member for optimization of care workflows across settings. Further, high-quality nursing data can assist in the optimal integration of registered nurses into high-value, lower-cost approaches to longitudinal care (Welton & Harper, Measuring Nursing Care Value, 2016). Figure 1 below provides a high-level timeline of significant events that have occurred in the evolution and development of SNTs. A detailed and expanded events timeline is in Appendix A. Figure 1. Consolidated SNT timeline Currently, the ANA recognizes two minimum data sets, two reference terminologies and eight interface terminologies for facilitating documentation of nursing care and interoperability of nursing data between multiple concepts and nomenclatures within IT systems (ANA, ANA Recognized Terminologies that Support Nursing Practice, 2012). The definitions of each of these types of terminologies are as follows:    Minimum data sets are “…a minimum, essential set of data elements with standardized definitions and codes collected for a specific purpose, such as describing clinical nursing practice or nursing management contextual data that influence care” (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record, 2008). Interface terminologies (point-of-care) include the actual terms/concepts used by nurses for describing and documenting the care of patients (individuals, families and communities) (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record, 2008). Reference Terminologies are designed to “…provide common semantics for diverse implementations” (CIMI, 2013) and ideally, they enable clinicians to use terms appropriate for their discipline-specific practices, then map those terms through a reference terminology to Identifying Challenges and Opportunities within Standard Nursing Terminologies 5 communicate similar meaning across systems (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008). Table 1 below includes the 12 SNTs by category. Table 1. ANA-Recognized Standard Nursing Terminologies 1. 2. 3. 4. 5. 6. 7. 8. III. Interface Terminologies Clinical Care Classification (CCC) System International Classification for Nursing Practice (ICNP) North American Nursing Diagnosis Association International (NANDA-I) Nursing Interventions Classification System (NIC) Nursing Outcomes Classification (NOC) Omaha System Perioperative Nursing Data Set (PNDS) ABC Codes Minimum Data Sets 1. Big Data Plays a Vital Role in Healthcare Sector

Nursing Minimum Data Set (NMDS) 2. Nursing Management Minimum Data Set (NMMDS) Reference Terminologies 1. Logical Observation Identifiers Names and Codes (LOINC) 2. SNOMED Clinical Terms (SNOMED CT) Landscape Analysis Approach The project team first performed an internet search to obtain background on standard nursing terminologies. Using information gathered in the search and focusing specifically on ANA-recognized SNTs, the project team proposed a list of interview contacts within each ONC-validated SNT organization. Interviews were conducted using an interview guide (Appendix B). For accuracy purposes, the project team used standardized definitions for the variables of current usage, existing interoperability and major barriers or issues to implementing and using SNT. Data on the following topics was collected for analysis:         SNT goals and objectives for the terminology ; Terminology versioning and release schedules; Latest version of SNT as well as update timing and methodology; Current usage and activities; Maintenance and sustainability issues; Level of interoperability with electronic health records; Major issues or barriers associated with integration and implementation; and The future state of the SNT. Discussions touched on each SNT’s perceived or actual barriers to interoperability, how easily an SNT is implemented within an EHR, and the typical process for that implementation. Details of those interviews are in Section IV: Summary of Background Data, below. After completion of interviews with terminology representatives, the project team approached three electronic health record developers to provided background on how SNTs are implemented and used in hospital and ambulatory health information technology applications. Although these interviews were Identifying Challenges and Opportunities within Standard Nursing Terminologies 6 unstructured, the project team developed a framework for guiding the discussion (Appendix C). Developer interviews were collated and overarching perspectives were identified for further discussion in Section VI: Health IT Developers – Perspectives. When all data collection was complete, the project team evaluated the information to identify gaps, similarities, barriers, challenges and opportunities related to the current status and use of SNTs. This information is in Section VII: Emerging Issues in Using SNTs. IV. Summary of Background Data The table below summarizes the background data collected during the landscape analysis. Table 2. Summary of Background Data Logical Observation Identifiers Names and Codes (LOINC) Alternative Billing Concepts (ABC) Codes Clinical Care Classification (CCC) System 2017 Original Publication Date SNOMED (1975) SNOMED II (1979) SNOMED CT (2002) 1994 2009 2000 2012 1991 International Classification for Nursing Practice (ICNP) NANDA International (NANDA-I) Nursing Interventions Classification System (NIC) Nursing Outcomes Classification (NOC) Omaha System Perioperative Nursing Data Set (PNDS) Nursing Minimum Data Set (NMDS) Nursing Management Minimum Data Set (NMMDS) 2015 Alpha v. (1996) 2002 1973 Schedule based on availability of resources. CCC System National Scientific Advisory Board meets annually. Released in May or June of the second year. Every three years. 2008 1992 Every five years. 2008 1997 Every five years. 2005 2011 1975 1999 Reviewed every two years. Every five years. NMDS is not in UMLS. NMMDS is not in UMLS. However, it is fully encoded with LOINC, which is in UMLS. 1983 No 1996/1997 No Terminology SNOMED Clinical Terms (SNOMED CT) Latest Update via UMLS 2017 Publication Schedule Twice annually: January and July. Twice annually: December and June. Identifying Challenges and Opportunities within Standard Nursing Terminologies 7 V. Findings A. Reference Terminologies Reference terminologies are designed to “…provide common semantics for diverse implementations” (CIMI, 2013) and ideally, they enable clinicians to use terms (synonyms) appropriate for their discipline-specific practices (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008) (Westra, et al., 2015). Big Data Plays a Vital Role in Healthcare Sector

The mapping of interface terminologies to reference terminologies allows a standard, shared vocabulary to communicate data across settings. The ANA-recognized reference terminologies are SNOMED CT and LOINC (characterized by the ANA as “multidisciplinary” terminologies). The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) require the use of a reference terminology (SNOMED CT and LOINC) for Meaningful Use incentive payments and for certification, respectively. 1. SNOMED CT SNOMED CT Latest Update via UMLS Original Publications 2017 SNOMED (1975) SNOMED II (1979) SNOMED CT (2002) Owned and distributed by SNOMED International, SNOMED CT is a comprehensive, multilingual clinical health care terminology used in more than 50 countries. When implemented into health IT, SNOMED CT provides a multidisciplinary approach to consistently and reliably represent clinical content in EHRs and other health IT solutions. SNOMED CT is important in health IT development and implementation as it supports the development of high-quality clinical content and provides a standardized way to record clinical data that enables meaning-based retrieval and exchange (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008). SNOMED CT content is represented using three different types of components, including concepts representing clinical meaning; descriptions that link terms to concepts; and relationships to link each concept to other related concepts. It is augmented by reference sets that support customization and enhancement of SNOMED CT, including subsets, language preferences and mapping from or to other terminologies. SNOMED CT maps provide explicit links to other health-related classifications and coding systems, e.g., to International Classification of Diseases (ICD-10). The U.S. Edition of SNOMED CT is the official source of SNOMED CT for use in the United States and is a standalone release that combines content of both the U.S. extension and the International release of SNOMED CT. For example, the U.S. Edition of SNOMED CT contains subsets representing Clinical Observations Recordings and Encoding (CORE) Problem list subset, as well as a Nursing Problem List subset to facilitate use of SNOMED CT as the primary coding terminology. Identifying Challenges and Opportunities within Standard Nursing Terminologies 8 Process for Updating/Publishing Standard SNOMED International provides its members with the ability to request changes to SNOMED CT through National Release Centers (NRC) in member countries. In some cases, changes may only be implemented in a national extension. If the change has international relevance, it is forwarded to SNOMED International for consideration of inclusion in the next release cycle. A new version of SNOMED CT is released to SNOMED International members in July and in January yearly. As the U.S. member of SNOMED International, NLM distributes SNOMED CT at no cost through the Uniform Medical Language System (ULMS) Metathesaurus via a licensing program. Usage/Activity SNOMED CT is required in the ONC Health IT Certification Program; specific certification criteria vary by edition (e.g., 2014, 2015). Big Data Plays a Vital Role in Healthcare Sector

Detailed information on each edition’s specific SNOMED CT criterion requirements are in the respective regulations and referenced in the “Standards Hub” on ONC’s website: https://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub Challenges Before SNOMED International purchased SNOMED CT from the College of American Pathologists (CAP), many ANA-recognized interface terminologies for nursing were integrated into SNOMED CT through the mapping of the nursing terms to valid concepts within SNOMED CT. However, SNOMED International did not purchase these maps from CAP, so they are not included in the international version of SNOMED CT. In addition, the NLM does not maintain mappings in the U.S. Edition as new editions are released. Therefore, any existing maps from nursing-specific terminologies to SNOMED CT would be maintained by each SNT. Opportunities SNOMED CT has a broad scope of coverage, including concepts across a wide range of multidisciplinary clinical information while maintaining the relationships between the concepts and supporting important capabilities such as clinical decision support, quality measurement and research initiatives. With greater inclusion of nursing content, SNOMED CT could be utilized at the user interface, eliminating the need for mapping and integration with other interface terminologies. Identifying Challenges and Opportunities within Standard Nursing Terminologies 9 2. Logical Observation Identifiers Names and Codes (LOINC) LOINC Latest Update via UMLS Original Publication 2017 1994 The Regenstrief Institute maintains LOINC as a comprehensive clinical terminology for identifying tests, measurements and observations. LOINC includes terms for laboratory test orders and results, clinical measures such as vital signs, standardized survey instruments and other patient observations. Comprised of more than 71,000 observation terms that primarily represent laboratory and clinical observations, it is available at no cost, and it is used extensively within U.S. health IT s …