Lecture 5
Standardized Terminology and
Language in Health Care
(Chapter 15)
http://www.csun.edu/~dn58412/IS531/IS531_SP16.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 component—Problem
Classification Scheme
• Intervention component—Intervention
Scheme
• Outcomes component—Problem 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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