Lecture 5

Standardized Terminology and

Language in Health Care
(Chapter 15)
http://www.csun.edu/~dn58412/IS531/IS531_S
P16.html

Learning Objectives
1. Standardized healthcare terminology and
its importance
2. Languages and Classifications : Billing,
Clinical, Nursing
3. Terminology structures: Classification
System vs. Reference Terminology
4. Benefits of using structured terminologies
within electronic healthcare records.
5. Issues and concerns
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Standardized Terminology
Also called Controlled Terminology
Structured and controlled languages
developed and approved by an authoritative
body
Healthcare terminology standards designed
to enable and support interoperability and
information sharing
Essential to the widespread implementation
of EHRs
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Healthcare Terminology
Standards
To represent, communicate, exchange,
manage and report data information, and
knowledge in healthcare
Ensure accurate, valid data collection
among various providers and care settings
Meaningful Use: exchange clinical
structured data in an accurate and
complete manner to improve costefficiency in client care
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Terminology Definitions . . .
Concept: an expression with a single
unambiguous meaning
Code: letters/characters/both to represent a
concept
Codified concepts
Clinical terminology: describe health
conditions and healthcare activities
Ontology: concepts are organized by their
meaning describe a definitional structurerelationship
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. . .Terminology Definitions
Reference Terminology: a set of concepts
with definitional relationship
To retrieve data across healthcare
settings, domains, and specialties
Point-of-care Terminology (interface
terminology): reference terminology in
familiar term to clinicians
to support the entry of patient-related
information into a computer program
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Types of Healthcare
Terminologies

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Technology Development
Guidelines

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Terminology and Nursing

Different terms indicate the same thing !
Need a standardized nursing language to
describe care across clinical settings and
specialists
How to document nursing problems,
interventions, and outcomes
To support interoperability, sharing
comparable data with other healthcare
organizations
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Languages and
Classifications . . .
Billing Codes
Mandated by Health Insurance Portability and
Accountability Act (HIPAA)
International Classification of Disease (ICD)
by World Health Organization (WHO):
for diagnosis reimbursement

Current Procedural Terminology (CPT)

American Medical Association(AMA):
for billing and reimbursement of outpatient
procedures and interventions
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ICD Examples

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CPT Examples

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Languages and
Classifications . . .

Clinical Terminologies

Unified Medical Language Systems (UMLS)

by National Library of Medicines (NLM),
recognized by American Nurses Association
(ANA)
Systematized Nomenclature of Human and
Veterinary Medicine Clinical Terms
(SNOMED-CT)
Logical Observation Identifiers, Name, and
Codes (LOINC)
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SNOMED-CT
Globally recognized terminology (concepts,
descriptions, and relationships)
Recognized by ANA
Promotes evidence-based practice
Undergoes review process to keep up to date
SNOMED-CT consists of 19 top-level
hierarchies (Cf. p.305)
Using parent-child relationship to build
vertical hierarchies
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SNOMED-CT Example

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LOINC
Logical Observation Identifiers, Names,
and Codes
Terminologies for laboratory and clinical
observations
For recording a single observation,
measurement, test result.

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LOINC Examples

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Languages and
Classifications . . .
Nursing Terminologies
Clinical Care Classification (CCC)
International Classification of Nursing Practice
(ICN)
North American Nursing Diagnosis Association
International (NANDA-I)
Nursing Intervention Classification (NIC)
Nursing Outcome Classification (NOC)
Omaha System
Perioperative Nursing Data Set (PNDS)
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Clinical Care Classification

(CCC) System

To facilitate patient care documentation at

the point of care
CCC of nursing diagnosis and outcome:
182 diagnosis concepts in categories and subcategories; 3 outcome qualifiers.

CCC for nursing intervention:

198 concepts in categories and sub-categories
to represent interventions, procedures,
treatments, and activities.

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International Classification
of Nursing Practice (ICNP)
For point-of-care and reference
terminology
Contains diagnoses, actions, and
outcomes in 7 axes (dimensions)

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ICNP Examples

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NANDA-I
North American Nursing Diagnosis
International
Each nursing diagnosis actual or potential
health problem has: description,
definition, defining characteristics
(manifestations, signs, symptoms)
13 domains , 7 axes(dimensions)

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NANDA Domains

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NANDA-I Examples

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Nursing Interventions
Classification (NIC)
Describe interventions used in nursing
care
30 classes, 7 domains and 542
interventions

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NIC Domains

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Nursing Outcomes
Classification (NOC)
Describe outcomes related to nursing
interventions
31 classes and 7 domains of outcomes
Each outcome has: definition, measurement
scale, associated indicators, supporting
references

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NOC Domains

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Omaha System
Research-based taxonomy for integrating
and sharing clinical data
Assessment componentProblem
Classification Scheme
Intervention componentIntervention
Scheme
Outcomes componentProblem Rating
Scale for Outcomes

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Omaha Systems

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Perioperative Nursing Data

(PNDS) Set
Provide wording and definitions for nursing
diagnoses, interventions, and outcomes
Allow collection data in a uniform way for
analyses
4 components, 75 diagnoses, 135
interventions, and 27 nurse-sensitive
patient care outcomes

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PNDS Example

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Benefits of Implementation
Client-specific benefits
Decreased costs
Increased quality
Improved outcomes
Improved safety

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Benefits of Implementation
Provider/Nursing Benefits
Complete access to data
Increased efficiency
Increased accuracy
Increased effectiveness
Improvement in client care

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Benefits of Implementation
Organizational Benefits
Decreased costs
Decision support
Outcome measurement
Data mining

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Issues and Concerns

Integrate systems with locally defined
concepts, not using standard terminology
Select which terminology(ies) to use
Point-of-care terms and synonyms for
clinical tasks must be locally developed:
potential problems for other local systems

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Nursing Assessment
Examples

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Nursing Diagnosis/Problem
Examples

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Nursing Intervention Examples

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Nursing Goal/Potential
Outcome Examples

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