Development, Evaluation, and Use of Reference Terminology for Nursing

Progress Report from the Nursing Terminology Summit

Nursing Terminology Summit 2002 Report to AMIA

Todays 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

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Overview of the Summit

Nursing Terminology Summit 2002 Report to AMIA

The Nursing Terminology Summit

Annual meetings since 1999  Participants from 5 continents  Diverse expertise and work settings


Nursing Terminology Summit 2002 Report to AMIA

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

Nursing Terminology Summit 2002 Report to AMIA

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 Summits 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 Summits 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
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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. 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. Nursing Terminology Summit
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Methods:


 

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 terminologiesNursing Terminology Summit
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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 O1A X X X

O2A O2A OE OE-O2A

Outcome Goal Goal Variance

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

Dimension

Subject of Information

Focus

Value

Site

Method
Derivation

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Nursing Diagnosis Reference Terminology Model

Dimension

Subject of Information

Focus

Judgment

Site

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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-RIMs ability to represent the intervention (instance diagrams) Initiated submission process for Education Use Cases at HL7 Patient Care Committee Terminology Summit Nursing
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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 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.

Sequence:
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 materials 4. 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 plan 10. Link finalized education plan to problem list 11. Provide links from standard plan to education knowledge bases. The links should be context specific. Post conditions: 12. Review and modify on a regularNursing Terminology Summit basis. 2002 31 Add to repository of education plans. Report to AMIA
1.

Use Case 1 - Research to Define Best Plan

Role
code :Committee
Evaluates Evaluates Observation Evaluates Evaluates Repeated for each review source for inclusion in the education plan

Participation
typeCode :Author

Procedure

Observation

Observation

Observation

code

: Breast Cancer : Literature Education Plan

moodCode :Definition statusCode :New activity_time : Any Review -Oncology Journal

code

code

code

code

:External
Requirements Review JCAHO

:Internal
Policies Review Educational Plans

:Other
Organization Review American Cancer Society

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 32 party payers.

Participation
typeCode :Target

moodCode

moodCode

:Event
statusCode

:Event
statusCode

moodCode

moodCode

:Event

:Event

:Completed
activity_time

:Completed
activity_time

statusCode statusCode

:Completed :Completed
activity_time activity_time

Role
code
Caregiver

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

:Any value:

:Any value:

:Any value:

Nursing Terminology Summit 2002 Report to AMIA

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

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 Harriss and Hellemans 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

Activity Diagram of nursing process [Y] More observations needed? [N] Make meta-observation 1-n Need for care? [Y] Define diagnoses 1- n End care process [N]

Make observation 1-n More

(meta-)

[Y]

[Y]

observations needed? [N]

Set expected outcomes 1 - n Define activities 1 - n

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Class model of the Nursing Process

findings:Observation leads to are based on clinical thinking relationship inferences:Observation gives as result clinical judgement relationship are determined from diagnosis:Observation suggests goal determination to solve problem relationship tries to solve gives focus to plan to reach the goals relationship tries to achieve planned_interventions:Procedure -Mood requires Assumed in model, but not worked out. implementation_of_care:Procedure describes care what is done and effects relationship -Mood need to have description of are goals met relationship

Assumed in Model and worked out.

goal:Observation

to be found in outcomes:Observation

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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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From the Models to Reference Terminology

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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 CT Nursing 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

Dimension

Subject of Information
Subject of Information

Focus
Interprets

Value

Site
Finding Site

Method
Method & Scales

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Nursing Diagnosis Reference Terminology Model

Dimension

Subject of Information
Subject of Information

Focus
Interprets

Judgment
Has interpretation

Site
Finding site

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ISO Nursing Diagnosis Model

NANDA Ineffective Individual Coping Has focus COPING Interprets:Ability to cope Has 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
Root procedure

Target
Has focus

Site
Procedure Site

Route
Approach

Subject of care Means

Using Recipient of care

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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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From Reference Terminology to Terminology Systems

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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:
 

Cerners Information ModelTM Controlled

medical terminology. - Provision of evidence based, executable knowledge that leverages the Information ModelTM architecture and structures.

Executable KnowledgeTM

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Cerner Information Model

TM

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 Cerners 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 Nursing Terminology Summit extensions. 2002 Report to AMIA 65

Cerner Information Model

TM

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. Cerners 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. Nursing Terminology Summit
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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 relevant item 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 - Prototyping
A system

Nutritional assessment
Appearance Underweight Mobility Weight Diagnosis
Mobile Overweight Immobile

kg
Nutrition Nutrition

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Methods - Activity diagramming

User Interface Dialogue Terminology

Select topic

Return topic

Get relevant item Put relevant item on form

Return relevant item

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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 tomorrows applications.
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Thank you!


Questions or comments?

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