Minnesota Recommendation to Use of a
Standard Nursing Terminology in All
Health Care Settings
Bonnie L. Associate Professor & Director Center for Nursing
Informatics, University of Minnesota, School of Nursing
Vision for Nursing Data in an Electronic Health Record
Supported Clinical Data Warehouse
Clinical Data
NMDS
Researchers
Professional
organizations
Other Data
Sets
Management
Data
NMMDS
Continuum of Care
2
Westra, B.L., Delaney, C.W., Konicek, D., & Keenan, G. (2008). Nursing Standards to
Support the Electronic Health Record. Nursing Outlook, 56, 258-266.e1
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Use of Nursing Terminologies
• Data Sets – Big Picture
• User Interface
• Health Information Exchange
4
NMDS
(clinical)
• Patient Demographics
– Date of birth
– Race/ Ethnicity
• Nursing Care Elements
– Nursing Dx
– Interventions
– Outcomes
• Service Elements
– Unique Number of
Principal Registered
Nurse Provider
– Discharge or Termination
Date *
NMMDS
(management)
• Environment
– Type of nursing delivery
unit/service
– Method of care delivery
• Nursing Care
Resources
– Management
demographic profile
– Staffing
• Financial Resources
– Payer type
– Reimbursement
5
User Interface Terminologies
• NNN
– NANDA - North American Nursing Diagnosis
Association
– NIC - Nursing Interventions Classification System
– NOC Nursing Outcomes Classification System
• CCC - Clinical Care Classification
• ICNP - International Classification of Nursing
Practice
• Omaha System
• PNDS - Perioperative Nursing Data Set
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Health Information Exchange
• Logical Observation Identifier Names &
Codes (LOINC®)
– Assessments
• Systematic Nomenclature of Medicine
Clinical Terms (SNOMED CT)
– Diagnoses/ Problems
– Interventions
– Outcomes
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INTEROPERABILITY
Minnesota e-Health Initiative
A public-private collaboration
established in 2004

Legislatively chartered

Coordinates and recommends
statewide policy on e-Health

Develops and acts on statewide ehealth priorities

Reflects the health community’s
strong commitment to act in a
coordinated, systematic and
focused way
“Vision: … accelerate the adoption and effective use of Health Information
Technology to improve healthcare quality, increase patient safety, reduce
healthcare costs, and enable individuals and communities to make the best
possible health decisions.”
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Minnesota Recommendation
1.All health and health care settings should
create a plan for implementing an (ANA)
recognized terminology within their (EHR).
2.Each health and health care setting type
should achieve consensus
3.Education should be provided and
guidance be developed for selecting the
terminology
Minnesota Recommendation
1.When exchanging a Consolidated Clinical
Document Architecture (C-CDA) document
with another setting for problems and care
plans, ise SNOMED-CT and LOINC
2.The Omaha System be used for exchange
between public health or communitybased settings if both use the same
terminology
Next
• Dr. Karen Monsen will report on the
current state of nursing terminology
implementation
• Break into groups and brainstorm 3
actions to achieve the recommendation
• Report back