Section 6.5 Optimize
Optimization Strategies for Adopting
Standard Terminology to Support Semantic
Interoperability
Standard terminology used at the point of care facilitates good documentation results in improved
care. Use this tool to assist with adoption of standard terminology.
Time needed: 2 hours
Suggested other tools: NA
Introduction
The health care industry has a number of terminologies. Each terminology generally has a primary
focus and the users become very familiar and comfortable with that terminology. A disadvantage is
that if each type of health care user has a different terminology, communication across providers is
difficult. To overcome lack of semantic interoperability among terminologies for use of health
information technology (HIT), many of them have been mapped to more broadly focused
terminologies that are more universally used.
How to Use
1. Appreciate the importance of adopting a standard terminology.
2. Understand the role of terminology mapping.
3. Adopt appropriate terminologies for each type of use.
Importance of Standard Terminology
This toolkit provides a summary of the major terminologies in use in healthcare (see Section 1.3
Interoperability for EHR and HIE). The most universally used health care terminology in the United
States is the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9CM). After October 1, 2014, it will be the International Classification of Diseases, Tenth Edition,
Clinical Modification (ICD-10-CM). This terminology is maintained by the federal government and
drives hospital reimbursement. It is also used for statistical reporting to the World Health
Organization.
The Current Procedural Terminology (CPT), maintained by the American Medical Association, is the
predominant terminology used for provider reimbursement. Although ICD-10-CM contains by far
more terms and greater specificity than its predecessors, it is still not as comprehensive or expressive
as SNOMED-CT, a multi-axial, clinical terminology created by the College of American
Pathologists and maintained by the International Health Terminology Standards Development
Organization. SNOMED-CT has been licensed for perpetual use in the United States by the National
Library of Medicine , which also supports the tools and processes to map many other terminologies
to SNOMED-CT—making it not only extremely comprehensive but universal.
Documentation is very important in reimbursement. (“If it’s not documented, it wasn’t done” is the
standard mantra.) However, standard terminology for documentation is increasingly important for
quality patient care, especially with greater reliance on HIE across disparate providers, without the
Section 6 Optimize—Optimization Strategies for Adoption of Standard Terminology to Support Semantic Interoperability - 1
immediate ability to validate understanding and offer clarification. Consider the example of a client
saying “I took an aspirin this morning.” If you are in the home, you can validate exactly what form of
“aspirin” is meant. However, if the client documents “aspirin” in a personal health record and you
review this between visits, you may not know whether it was an acetaminophen, ibuprofen, or other
form of pain reliever.
There are many uses for standard terminology:
 Clarity in documentation

Clarity in HIE

Ability to generate valid reports

Generation of knowledge by aggregating a large volume of data and identify useful patterns

Incorporation of new knowledge into clinical protocols that improve quality of care

Ability to develop logic rules for clinical decision support systems
Mapping Terminologies
Because we want documentation to be precise and specific to the user’s needs as well as
standardized, a number of terminologies have emerged over the years. Several of these are used to
describe drugs, including the National Drug Code and a constellation of RxNorm drug databases—all
consistent with each other yet offering additional and corollary information. Nursing has many
terminologies. There is regularly serious consideration of using SNOMED-CT directly for all aspects
of electronic health record (EHR) documentation in support of HIE. If this happens, it will be greatly
facilitated by the NLM mapping—so long as current documentation adheres to the standard
terminologies for which there are maps. If any individual user or group of users fail to use standard
terminology, it will be impossible to accurately correlate a proprietary term with a standard term.
The illustration below demonstrates how a single concept, “acute pain” can be documented by a
nurse in a hospital which the hospital’s EHR stores as a (North American Nursing Diagnosis
Association) NANDA code (00132), sent to a home health agency (HHA) nurse, whose EHR stores
“acute pain” as an Omaha code (24). When ready to generate reports and knowledge, a health
information exchange organization (HIO) with a terminology server can map both NANDA and
Omaha codes to SNOMED-CT (274663001). The use of SNOMED-CT, combined with the various
nursing terminologies1 , provides unambiguous data storage and retrieval along with the richness
required for clinicians to use the data. This architecture allows coded data to be converted into
meaningful reports for secondary data uses.
1
For a comprehensive discussion of the nursing terminologies, see: Lundberg, C. et al. (June, 2008). Selecting a
Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care.
Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf
Section 6 Optimize—Optimization Strategies for Adoption of Standard Terminology to Support Semantic Interoperability - 2
Terminology Adoption
Nurse adoption of the appropriate terminology is obviously critical to incorporating standard
terminology into our EHRs and make use of it in HIE, as well as knowledge generation and other
uses which an HIO can support.
Nurse adoption of a standard terminology appears to be heavily influenced by training, previous
usage,2 the presence and use of care plans3, especially via EHRs that incorporate nursing terminology
through templated menu selection, and potentially the requirement for standard nursing terminologies
to be used as part of the collection of federally required data sets.
Although most four-year nurse training programs cover nursing terminologies, most other nurse
training programs do not address terminologies. Lack of familiarity with the terminology and a lack
of understanding why a standard terminology is important, may explain a lack of interest among
nurses when it comes to use of standard terminologies in EHRs and other HIT. Few EHRs have
embedded nursing terminologies and there are no requirements to do so. This is beginning to change
for hospitals and their use of the NANDA terminology, although even in hospitals nursing
terminologies often are still often proprietary.
The Omaha System is the predominant nursing terminology used in home health care. There are
some home health EHR vendors who support the Omaha System. The Minnesota Omaha System
Users Group is an excellent resource for care plans and other tools. (See:
http://omahasystemmn.org/KBS_care_plans.php. )
In 2013, the federal Office of the National Coordinator for Health Information Technology (ONC)
has begun working with the American Health Information Management Association and Regenstrief
2
Thede, L., Schwiran, P., (February 25, 2011) "Informatics: The Standardized Nursing Terminologies: A National
Survey of Nurses’ Experiences and Attitudes - Survey I*" OJIN: The Online Journal of Issues in Nursing Vol. 16
No. 2. Available at:
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/
Standardized-Nursing-Terminologies.html
Keenan, G. Standardized Nursing Terminology and Communication Protocols Lead to Increased Use of Patients’
Plan of Care, Agency for Healthcare Research and Quality (AHRQ), AHRQ Health Care Innovations Exchange.
Available at: http://www.innovations.ahrq.gov/content.aspx?id=1848
3
Section 6 Optimize—Optimization Strategies for Adoption of Standard Terminology to Support Semantic Interoperability - 3
Institute, which manages the standard terminology LOINC (Logical Observations Identifiers Names
and Codes), to incorporate LOINC codes into the Outcome and Assessment Information Set (OASIS)
C version as a first step toward interoperability standards. (See:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/OASISC.html.
In the absence of federal mandate, home health agencies looking to improve the quality of care
offered through their nurses should consider taking the following steps:
1. Determine how standard terminology use fits the agency’s vision and goals.
2. Learn more about standard terminologies and educate nurse leaders who can translate that
knowledge into practical applications.
3. Include standard terminologies in requirements specifications for EHR. If your agency
already has an EHR, seek information from the vendor as to when standard terminologies
may be incorporated. If there are no such plans, encourage consideration.
4. Review requirements for HIE in your HIO. If the HIO has a terminology server, use this as
leverage with the agency’s EHR vendor.
5. Evaluate ways to use care plans and other tools that incorporate standard terminologies in
conjunction with the agency’s EHR or other health information technology (HIT).
6. As standard terminologies become available in the EHR, train nurses on how and why to use
them.
7. Produce reports that demonstrate the results of using standard terminologies.
8. Monitor the research and potential for requirements for adoption of standard terminologies so
your agency can be ahead of the curve in preparing for their use.
Copyright © 2013
Updated 11-20-13
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