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Nursing Terminology Summit

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  • Determine the adequacy of the model to represent concepts and relationships on a sample of terminologies
  • Determine the adequacy of the model to represent concepts and relationships on a sample of terminologies
  • The intervention patient education about breast cancer was chosen because it was sufficiently different from other medical processes already considered by HL7, and because it was thought to represent sufficiently the issues surrounding both the definition and execution of nursing process.
  • Transcript

    • 1. Nursing Terminology Summit 2002 Report to AMIA 1 Development, Evaluation, and Use of Reference Terminology for Nursing Progress Report from the Nursing Terminology Summit
    • 2. Nursing Terminology Summit 2002 Report to2 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
    • 3. Nursing Terminology Summit 2002 Report to3 Overview of the Summit
    • 4. Nursing Terminology Summit 2002 Report to4 The Nursing Terminology Summit  Annual meetings since 1999  Participants from 5 continents  Diverse expertise and work settings
    • 5. Nursing Terminology Summit 2002 Report to5 Summit Steering Committee  Judy Ozbolt, Chair  Ida Androwich  Suzanne Bakken  Patricia Button  Nicholas Hardiker  Charles Mead  Judith Warren  Christine Zingo
    • 6. Nursing Terminology Summit 2002 Report to6 Summit Sponsors  NLM  HRSA  AMA  AMIA*  Cerner*  HIMSS  IDX  3M  McKesson*  Siemens*  SNOMED* *Sponsor in 2002
    • 7. Nursing Terminology Summit 2002 Report to7 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
    • 8. Nursing Terminology Summit 2002 Report to8 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)
    • 9. Nursing Terminology Summit 2002 Report to9 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
    • 10. Nursing Terminology Summit 2002 Report to10 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
    • 11. Nursing Terminology Summit 2002 Report to AMIA 11 Development, Evaluation, and Use of Reference Terminology: The Big Picture
    • 12. Nursing Terminology Summit 2002 Report to12 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
    • 13. Nursing Terminology Summit 2002 Report to13 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
    • 14. Nursing Terminology Summit 2002 Report to14 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.
    • 15. Nursing Terminology Summit 2002 Report to15 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
    • 16. Nursing Terminology Summit 2002 Report to16 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.
    • 17. Nursing Terminology Summit 2002 Report to17 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
    • 18. Nursing Terminology Summit 2002 Report to AMIA 18 Developing and Evaluating the Models Progress at the Summit, 1999-2002
    • 19. Nursing Terminology Summit 2002 Report to AMIA 19 A Domain Concept Model for Findings: Similarities and Differences among Diagnoses, Goals, and Outcomes Judith J. Warren
    • 20. Nursing Terminology Summit 2002 Report to20 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
    • 21. Nursing Terminology Summit 2002 Report to21 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
    • 22. Nursing Terminology Summit 2002 Report to22 Findings Reference Terminology Model Value Method Derivation Dimension Subject of Information Focus Site
    • 23. Nursing Terminology Summit 2002 Report to23 Nursing Diagnosis Reference Terminology Model Dimension Subject of Information Focus Site Judgment
    • 24. Nursing Terminology Summit 2002 Report to AMIA 24 Terminology and Information Models for Nursing Actions: The Use-Case Approach to Development and Testing Pat Button
    • 25. Nursing Terminology Summit 2002 Report to25 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.
    • 26. Nursing Terminology Summit 2002 Report to26 Goal of the Intervention Team  Ensure that the HL7 RIM supports nursing terminology and that it provides a foundation for integrating nursing intervention concepts.
    • 27. Nursing Terminology Summit 2002 Report to27 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
    • 28. Nursing Terminology Summit 2002 Report to28 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)
    • 29. Nursing Terminology Summit 2002 Report to29 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
    • 30. Nursing Terminology Summit 2002 Report to30 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.
    • 31. Nursing Terminology Summit 2002 Report to31 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 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. 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.
    • 32. Nursing Terminology Summit 2002 Report to32 Use Case 1 - Research to Define Best Plan code : Breast Cancer Education Plan moodCode :Definition statusCode :New activity_time : Any Procedure value: Yes, include in plan or No, do not include code : Literature Review -- Oncology Journal moodCode :Event statusCode :Completed activity_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 code Caregiver Role typeCode :Author Participation code :Committee Role value: Yes, include in plan or No, do not include code :External Requirements Review – JCAHO moodCode :Event statusCode :Completed activity_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 :Internal Policies Review – Educational Plans moodCode :Event statusCode :Completed activity_time :Any Observation value: Yes, include in plan or No, do not include code :Other Organization Review – American Cancer Society moodCode :Event statusCode :Completed activity_time :Any Observation value: Yes, include in plan or No, do not include Evaluates Evaluates Evaluates
    • 33. Nursing Terminology Summit 2002 Report to33 Findings: Four Perspectives  Methodology used  Implications for HL7 RIM  HL7 RIM implications for terminology modeling and domain terminologies  General terminology implications
    • 34. Nursing Terminology Summit 2002 Report to34 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
    • 35. Nursing Terminology Summit 2002 Report to35 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)
    • 36. Nursing Terminology Summit 2002 Report to36 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
    • 37. Nursing Terminology Summit 2002 Report to37 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
    • 38. Nursing Terminology Summit 2002 Report to38 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
    • 39. Nursing Terminology Summit 2002 Report to39 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.
    • 40. Nursing Terminology Summit 2002 Report to40 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
    • 41. Nursing Terminology Summit 2002 Report to AMIA 41 An Information Model of the Nursing Process William Goossen
    • 42. Nursing Terminology Summit 2002 Report to42 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.
    • 43. Nursing Terminology Summit 2002 Report to43 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.
    • 44. Nursing Terminology Summit 2002 Report to44 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.
    • 45. Nursing Terminology Summit 2002 Report to45 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-) observations needed? [Y] [N] [Y] Define diagnoses 1- n [Y] [N] End care process Activity Diagram of nursing process
    • 46. Nursing Terminology Summit 2002 Report to46 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
    • 47. Nursing Terminology Summit 2002 Report to47 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
    • 48. Nursing Terminology Summit 2002 Report to AMIA 48 From the Models to Reference Terminology
    • 49. Nursing Terminology Summit 2002 Report to AMIA 49 Representing Nursing Concepts and Relationships in SNOMED CT Deb Konicek
    • 50. Nursing Terminology Summit 2002 Report to50 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
    • 51. Nursing Terminology Summit 2002 Report to51 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
    • 52. Nursing Terminology Summit 2002 Report to52 Findings Reference Terminology Model Value Method Dimension Subject of Information Focus Site Interprets Subject of Information Finding Site Method & Scales
    • 53. Nursing Terminology Summit 2002 Report to53 Nursing Diagnosis Reference Terminology Model Dimension Subject of Information Focus Site Judgment Interprets Has interpretation Finding site Subject of Information
    • 54. Nursing Terminology Summit 2002 Report to54 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
    • 55. Nursing Terminology Summit 2002 Report to55 ISO Nursing Intervention Model Action Site Route Using Means Target Subject of care Root procedure Has focus Recipient of care Procedure Site Approach
    • 56. Nursing Terminology Summit 2002 Report to56 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
    • 57. Nursing Terminology Summit 2002 Report to AMIA 57 From Reference Terminology to Terminology Systems
    • 58. Nursing Terminology Summit 2002 Report to AMIA 58 Reference Terminology and the Next Generation of Systems: Advances at Cerner, McKesson, and Siemens Pat Button
    • 59. Nursing Terminology Summit 2002 Report to59 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.
    • 60. Nursing Terminology Summit 2002 Report to60 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.
    • 61. Nursing Terminology Summit 2002 Report to61 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.
    • 62. Nursing Terminology Summit 2002 Report to62 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.
    • 63. Nursing Terminology Summit 2002 Report to63 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.
    • 64. Nursing Terminology Summit 2002 Report to64 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.
    • 65. Nursing Terminology Summit 2002 Report to65 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.
    • 66. Nursing Terminology Summit 2002 Report to66 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.
    • 67. Nursing Terminology Summit 2002 Report to67 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.
    • 68. Nursing Terminology Summit 2002 Report to AMIA 68 Direct Use of Formal Terminology Systems in Clinical Applications: Difficulties and Solutions Suzanne Bakken and Nicholas Hardiker
    • 69. Nursing Terminology Summit 2002 Report to69 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
    • 70. Nursing Terminology Summit 2002 Report to70 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
    • 71. Nursing Terminology Summit 2002 Report to71 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
    • 72. Nursing Terminology Summit 2002 Report to72 Methods - Use case analysis A System Present relevant item for selection Nurse
    • 73. Nursing Terminology Summit 2002 Report to73 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
    • 74. Nursing Terminology Summit 2002 Report to74 Methods - Prototyping A system Nutritional assessment UnderweightAppearance Mobility Weight kg Overweight Mobile Immobile Diagnosis Nutrition Nutrition
    • 75. Nursing Terminology Summit 2002 Report to75 Methods - Activity diagramming User Interface Dialogue Terminology Select topic Return topic Get relevant item Return relevant item Put relevant item on form
    • 76. Nursing Terminology Summit 2002 Report to76 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
    • 77. Nursing Terminology Summit 2002 Report to77 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.
    • 78. Nursing Terminology Summit 2002 Report to78 Thank you!  Questions or comments?