Standardized Terminologies (ST) in Practice. Standardized terminologies (STs) contribute to the development of knowledge because they ensure that all professionals share the same understanding or meaning of a given concept, to clarify communication, facilitate research, and provide structure for decision support tools and EHRs. As you look at the Foundation of Knowledge model, STs support knowledge acquisition, dissemination, generation, and processing.
STs are structured, controlled languages developed to represent concepts in a given domain in a clear, unambiguous fashion that conveys the exact same meaning for data, information, and knowledge across settings, regions, and even different countries. This consistency affords access to information and knowledge when it is needed without regard to the current model or period of care. STs are key to the development of an EHR in order to represent, communicate, exchange, reuse, and report data, information, and knowledge, including Meaningful Use criteria (Matney & Lundberg, 2013). In addition to vocabularies, terminology standards also include nomenclatures, classification systems, data sets, and code sets. Each will be discussed briefly.
Guidelines for the development of standard terminologies were established during the late 1990s and remain in use today (Cimino as cited in Matney & Lundberg, 2013). Cimino’s guidelines included 12 items. Guidelines addressed aspects that include content, concepts, and identification of concepts, hierarchy, relationships, and formal definitions. Terminologies are based upon concepts rather than terms and allow for growth over time. Also, once concepts enter a terminology, they should not be deleted or reused. While a concept has a single unambiguous meaning, it can have one or more representations or synonyms. Each concept has a unique identifier known as a code, which is made of alphanumeric characters. The code supports tracking data for various purposes, including evidence-based practice, decision support, and reports.
Despite the intent of STs to represent concepts in a clear, unambiguous fashion, the numbers and different types of terms used to discuss STs can be confusing initially. Some of these terms include the following.
As you might guess, the terms nomenclature, classification, and taxonomy are sometimes used interchangeably.
It is likely that you have or will be hearing about two other STs that are used for reimbursement purposes the International Statistical Classification of Diseases and Related Health Problems (ICD) and Current Procedural Terminology (CPT). ICD is maintained by the World Health Organization. It provides a description and a classification of known diseases and injuries. Every condition has a unique code up to six characters long. ICD is currently used for the following purposes:
- Collection of morbidity and mortality statistics
- Automated clinical decision support
- Assignment of codes to medical diagnoses and procedures associated with hospital utilization in the United States
ICD is presently in its tenth version which has required some modifications and created some issues. CPT provides unique billing codes for services rendered. It is a list owned and maintained by the American Medical Association. CPT codes have been developed via a committee process rather than a basis in evidence.
The Benefits of ST Adoption and Use
ST improves communication, supports data reuse, contributes to the further development of nursing knowledge, and provides a framework for EHRs. Standard terminologies support the collection of data that can provide more information, not only on what nurses do but the amount of time spent in various activities and their contributions to patient outcomes. This is the type of information that can be used to cost out nursing services or to provide justification for staffing ratios. In this respect, many nurse leaders anticipate that STs within EHRs will provide information that is meaningful not just to qualify for financial incentives but for nurses and nursing.
According to Matney and Lundberg (2013), the beneficiaries of ST adoption and use include the nurse, patient, providers, healthcare delivery systems, and because they support Meaningful Use, one might say that data collected as a result can provide information that can be analyzed to achieve better population health and decision support. Patients benefit via decreased costs, improved quality of care, improved outcomes, and improved safety. Providers benefit through improved access to data along the continuum of care. Healthcare delivery systems benefit through the structured vocabularies within and between information systems that provide access to complete and accurate data. Nurses gain efficiency, accuracy, and effectiveness, resulting in improved patient care and outcomes. STs support the integration of evidence-based practice. Organizations benefit from resulting cost savings, the ability to support clinical decision support, improved outcomes measurement, the ability to collect core measures for Meaningful Use, and the ability to use analytics to examine the data collected for multiple purposes that will allow them to serve their communities better. Because STs can help to yield cost savings and better management of population health, they should help to lower overall healthcare costs that we pay as a nation.
The Process for Acceptance and Revision of ST (Standardized Terminologies (ST) in Practice)
Earlier, we spoke about the guidelines for the development of standard terminologies, but acceptance needs to be addressed at two levels. The first level occurs at the organizational level that provides oversight for the development (and revision) process. For nursing languages in North America, this responsibility lies with a committee within the American Nurses Association (Schwirian, 2013). ICNP falls under the International Council of Nurses (ICN).
The second level entails acceptance at the international, national, and local levels essentially, one organization at a time. This requires an appreciation on the part of administrators and staff of the potential that STs hold. It is essential that all nurses understand the need to use STs to demonstrate nursing’s contributions to patient care. The benefits associated with STs cannot be realized if they are not used.
Issues with Adoption and Use of ST
ST use can be challenging because many existing systems still in use have locally defined concepts, which must be linked to STs. This situation is changing due to federal incentives to spur the adoption of technology capable of collecting Meaningful Use criteria EHRs that qualify for Meaningful Use incentive monies integrate SNOMED, which, while not specific to nursing, supports nursing STs. Harkiker (2012) noted that models of terminology use have been developed to ease the integration of STs into information systems and EHRs. Education and good screen design can also play an important part in the integration and acceptance issue.
On another front, Schwirian (2013) noted the mixed blessing of having multiple nursing STs, which may impede the rate of adoption and optimal use. While it is unlikely that nursing will agree on a single ST in the near future, there are issues of permissions and fees with the use of most STs. In a cost-conscious, penny-pinching, healthcare delivery environment, these costs may influence adoption decisions. Both the Clinical Care Classification (CCC) and the Omaha systems fall in the public domain, however, so that their use is free.
The Role of the APN in Adopting Standardized Terminologies (ST) in Practice
As a leader in areas of nursing practice, the APN needs to be aware of the many potential benefits of STs for healthcare providers, the healthcare organization, and patients in terms of improved access of information, visibility, cost reduction, and possible contributions to transforming population health and achieving healthcare reform as STs enable the collection of quality, reusable data, information, and knowledge on a level that has never before been possible. In addition to knowledge, there is a responsibility to educate other nurses and peers and to support local and regional efforts toward achieving true health information exchange yet another benefit that STs can facilitate.