Standardized TerminologyTOP OF PAGE
What are the reasons why nurses need to be concerned about standardized terminology? In many prelicensure nursing programs, medical terminology is a required course. If it is not required, it is certainly implied that nurses be able to speak “medical.” However, using standardized terminology as it relates to nursing practice is imperative so that we can communicate among each other, other disciplines, and those who review nursing outcomes or data and provide reimbursement for services provided.
Benefits and Challenges of Standardized TerminologyTOP OF PAGE
Imagine a room filled with 13 people who are all speaking different languages with no means for translation. That is what it is like for a computer to try to connect various programs when each computer is using a different terminology. Hebda and Czar (2013) offer a detailed description of the need for standardized terminology in order to collect aggregate data.
There have been many conversations over the years about the need for increased visibility of nursing activities. Nursing does not charge for individual services; therefore, patients do not see an accounting of specific nursing care that they received when they review their bills. Nurses go from one patient to the next, taking care of a multitude of needs, without documenting each and every activity or thought process for care coordination. Much of nursing care reflects the concept of data-to-wisdom that we discussed in Week 1, and it may not be documented as such.
If nursing data are to be visible, nursing activities must be retrievable, and for them to be retrievable, nursing concepts and activities have to be integrated into a Clinical Information System (CIS) or Health Information System (HIS) by using a language. That language must speak to other languages in the system, such as finance, resource management, and interdisciplinary and multidisciplinary partners. For example, we know that oral hygiene is an important personal care activity for our patients. If we want to be able to capture the nursing time, money, and resources spent on oral hygiene, first we have to be able to designate a category (personal hygiene), and then a term (oral care) that all system components are able to read.
Part of managing technological change as defined by Lorenzi and Riley (2010) is the understanding of unique aspects of nursing informatics and its application to the healthcare practice environment. A function of nurses in all practice settings is a commitment to change that is evidenced across nursing specialties and practice environments (Morrison & Symes, 2011). It is important that the nurse become familiar with nursing informatics language because it will increasingly be used in the future, particularly when it comes to meaningful use, which is a term discussed in another lesson. Nurses benefit from establishing relationships with an informatics nurse specialist who serves in one of the many roles emerging in this specialty.
Reflect on the nursing language that you use in your practice. Is the language shared by practitioners outside of your organization, in other words, do you speak the same language as your peers, perhaps in a different practice setting? If not, has this caused any problems with communication?
A systematic approach to naming is known as a nomenclature. Such terms are typically described according to a pre-established set of rules. Examples of nursing nomenclatures important to practice include SNO-MED and ICNP© (Coenen & Kim, 2010).
Informatics nurse specialists have documented current efforts toward meeting the demand for a reference terminology of nursing concepts. These specialists are building on the foundation of existing interface and administrative terminologies, and are collaborating with efforts to develop terminology across the spectrum of healthcare. Such efforts address the “languages” spoken by nurses in a variety of practice settings. These include but are not limited to
NANDA – North American Nursing Diagnosis Association;
NMDS – Nursing Minimum Data Set;
HHCC – Home Healthcare Classification;
OMAHA system, used in home care, hospice, public health, and prisons;
NIC/NOC – Nursing Interventions Classification (NIC)/Nursing Outcomes Classification (NOC); and
PCDS – Patient Care Data Set.
Let’s look at each language in more detail.
NANDA. The North American Nursing Diagnosis Association (NANDA) was first developed in 1950, and to date has grown to include a multitude of diagnoses (Whitley, 2009). Prelicensure nursing education programs often include nursing diagnoses in their curricula and serve as the basis for writing nursing care plans.
NMDS. The Nursing Minimum Data Set (NMDS) was first explained in 1972 through nursing research at the University of Iowa and included a focus on nursing diagnoses, nursing interventions, nursing outcomes, and intensity of nursing care (Fetter, 2009c). The NMDS evidences support for the notion that health and nursing informatics encompasses pivotal roles of data and information. NMDS identifies and documents essential data using nursing vocabularies and ensures adequate computer-based patient record systems. Through NMDS, nursing data, information, and knowledge is accessed and built using telecommunications to support care delivery and empowering the consumer through health informatics. NMDS transforms education and enhances nursing decision making through national research agendas.
HHCC & OMAHA. The Home Healthcare Classification was developed by Saba in 1991 and includes a multitude of nursing diagnoses and interventions, while the OMAHA system was developed in 1992 and includes numerous problems with interventions and outcome measures pertinent to community health. Informatics nursing specialists suggest that the adequacy and usefulness of a proposed-type definition for nursing activity concepts is necessary for representing nursing activity concepts within a concept-oriented terminological system (Lundberg et al., 2008).
NIC/NOC. The Nursing Intervention Classification (NIC) and the Nursing Outcomes Classification (NOC) systems were first developed in 1987, with numerous interventions represented for the NIC as well as numerous outcomes represented across a variety of domains and classes for the NOC. In exploring NIC/NOC, note that the attempt to produce a scientific classification of nursing work represents one important direction for building nursing knowledge. At the same time, it represents a significant strategy for defending the profession of nursing.
PCDS. The Patient Care Data Set (PCDS) encompasses patient problems, patient care goals, goal evaluation, and patient care orders. According to Lake, Moss, and Duke (2009), there is a need to seek consensus on a common approach to the development of nursing terminology standards for use in information systems.
The aforementioned nursing languages are not the only ones. Hebda and Czar (2013, p. 304) provide a comprehensive listing of ANA-recognized nursing languages.
Table 15-5 ANA Recognized Nursing Languages
TerminologyWeb siteDiagnosis/ProblemInterventionOutcomeOtherAlternative Billing Concepts (ABC Codes)http://www.abccodes.com Billing CodesClinical Care Classification (CCC)http://www.sabacare.comXXX International Classification of Nursing Practice (ICNP)http://www.icn.ch/icnp.htmXXXAssessmentLogical Identifiers Names and Codes (LOINC)http://loinc.org/ XAssessmentNorth American Nursing Diagnosis International (NANDA-I)http://www.nanda.orgX Nursing Intervention Classification (NIC)http://www.nursing.uiowa.edu/cnc/ X Nursing Outcomes Classification (NOC)http://www.nursing.uiowa.edu/cnc/ X Nursing Management Minimum Data Sethttp://www.nursing.umn.edu/ ICNP/USANMMDS/home.html Nursing Management CodesNursing Minimum Data Sethttp://www.nursing.umn.edu/ICNP/ Omaha Systemhttp://www.con.ufl.edu/omahaXXX Perioperative Nursing Data Set (PNDS)http://www.aorn.orgXXX SNOMED-CThttp://www.ihtsdo.org/snomed-ctXXX
HEBDA, TONI LEE; CZAR, PATRICIA, HANDBOOK OF INFORMATICS FOR NURSES & HEALTHCARE PROFESSIONALS, 5th Edition, © 2013. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.
Reimbursement IssuesTOP OF PAGE
As we have become more and more aware, properly documented nursing care drives reimbursement in our various practice settings. Using proper terminology and capturing nursing’s unique contributions to healthcare is of the utmost importance. No discussion of reimbursement is more important than the tie between nursing care and patient satisfaction.
Nurses are held to a very high standard of care, and one way that care is being rated is by HCAHPS. Nurses in acute care settings may be familiar with Hospital Consumer Assessment of Healthcare Providers (HCAHPS), which is a standardization survey that collects data for measuring patients’ hospital experiences. Many hospitals and health systems follow these standards to help improve the quality and safety of patient care. Do you know that HCAHPS scores can be accessed on their website for recommendations of the best- or worst-scoring hospitals within your area?
According to the Centers for Medicare and Medicaid Services (CMS, 2013), three broad goals have shaped HCAHPS. To begin with, the survey is designed to produce data about a patient’s perspective of care that allows for objective and meaningful comparisons of hospitals on topics that are important to patients. Secondly, public reporting of the survey results creates new incentives for hospitals to improve quality of care. And finally, public reporting serves to enhance accountability in healthcare by increasing transparency of the quality of hospital care provided in return for the public investment.
Should patient satisfaction scores be linked to reimbursement? What “little things” can you do to improve patient satisfaction that may eventually impact reimbursement?
Summary: Check Your KnowledgeTOP OF PAGE TranscriptReferencesTOP OF PAGE
Coenen, A., & Kim, T. (2010). Development of terminology subsets using ICNP. International Journal of Medical Informatics, 79(7), 530–538.
Fetter, M. (2009b). A language of precision. Issues in Mental Health Nursing, 30(2), 133–134.
Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed.). Boston, MA: Pearson.
Lorenzi, N. M. & Riley, R. T. (2010). Managing technological change: Organizational aspects of health informatics. New York, NY: Springer Publishing Company.
Lundberg, C., Brokel, J., Bulechek, G., Butcher, H., Martin, K., Moorhead, S., & … Giarrizzo-Wilson, S. (2008). Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online Journal of Nursing Informatics, 12(2).
Morrison, S. M., & Symes, L. (2011). An integrative review of expert nursing practice. Journal of Nursing Scholarship, 43(2), 163–170.
Perkins, S., & Larson, G. (2010). Navigating ICD-10: How to get from point A to point B. Health Management Technology, 31(12), 1–7.
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