M8120
Data for Evidence-based Practice
Fall 2001
Outline
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Background
Nursing terminologies
Other standardized terminologies
Concept-oriented terminologies
Model testing
– Interventions
– Assessments
– Diagnoses
• Standardization initiatives
• Impact of concept-oriented terminologies
Foundation for Evidence-based Practice
Standardized terminologies
• Digital sources of evidence
• Standards that facilitate health care data
exchange
• Informatics competencies
• Informatics processes that support the
acquisition and application of evidence to a
specific clinical situation
What Data Do We Need for
Evidence-Based Practice?
• Data and information about the patient
• Data and information about the context
of care
• Domain information and knowledge
(“the evidence”) from systematic inquiry
and other sources
Standardized Terminologies
• Capture and store patient care data
(including context of care) in a
standardized fashion
• Facilitate data re-use and aggregation
• Index information and knowledge
resources (“the evidence”)
• Facilitate information retrieval
Standardized Terminologies
System
NANDA Taxonomy 1
Problem/Dx
Interventions
Outcomes
x
Current Procedural Terminology
x
Nursing Interventions Classification
x
Omaha System
x
x
x
Home Health Care Classification
x
x
x
International Classification of Diseases
x
SNOMED Clinical Terms
x
x
x
Nursing Outcomes Classification
x
Medcin
x
x
First Data Bank Pharmacy KB
x
x
x
Background
• Nursing Minimum Data Set
– Nursing diagnoses
– Nursing interventions
– Nursing-sensitive outcomes
– Nursing care intensity
– Primary nurse
– + others not specific to nursing
Nursing Systems
• Diagnoses/judgments
– NANDA Taxonomy I
– Georgetown Home Health Care
Classification
– Patient Care Data Set
– Omaha System
– International Classification of Nursing
Practice
Nursing Systems
• Interventions
– Nursing Interventions Classification
– Georgetown Home Health Care
Classification
– Patient Care Data Set
– Omaha System
– International Classification of Nursing
Practice
Nursing Systems
• Outcomes
– Nursing Outcomes Classification
– Georgetown Home Health Care
Classification
– Omaha System
– International Classification of Nursing
Practice
• Goals
– Patient Care Data Set
Nursing Interventions Classification
• Three-tiered taxonomy
– 7 domains (e.g., Health System)
– 30 classes (e.g., Health System
Management)
– 486 interventions (e.g., Critical Path
Development)
– Plus related activities (e.g., Review current
standards of practice related to patient
population)
Home Health Care Classification
• 20 care components
• 145 nursing diagnoses
• Interventions
– 161 interventions (e.g., Wound Care)
– 4 modes of nursing action - assess, care,
teach, manage
• Outcomes
– Stabilized, deteriorated, improved
Patient Care Data Set
• Care Components - 22
– Pre-, Intra-, or Post-Procedure
• Problems - 363
– Cardiac electrophysiology alteration
• Patient Care Orders - 1357
– Teach and encourage to use stress
management techniques
• Patient Goals - 308
– Patient will maintain or achieve hemodynamic
stability
International Classification of
Nursing Practice (ICNP)
• Product of the International Council of
Nurses
• Phenomena
• Nursing actions
• Nursing-sensitive patient outcomes
Other Important Standardized
Terminologies
• International Classification of Diseases
• Physician’s Current Procedural
Terminology
• SNOMED Clinical Terms
• Logical Observations, Identifiers,
Names, and Codes (LOINC)
Issues Related to Standardized
Terminologies
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Multiple terminologies exist
Large number of terms
Terms vary in level of abstraction
Areas of overlap
Areas of gap
“Computability”
Potential Solutions
• Uniform language
• Unified Medical Language System
• Concept-oriented “reference”
terminologies
What is the UMLS?
• Long-term NLM research and development effort
designed to facilitate the retrieval and integration of
information from multiple machine-readable
biomedical information sources
• Includes development of machine-readable
“knowledge sources” that can be used by a wide
variety of application programs to compensate for
differences in the way concepts are expressed in
different machine-readable sources and by different
users
Contents
• Metathesaurus
• Specialist Lexicon
• Semantic Network
• Information Sources Map
Metathesaurus
• Semantic information about biomedical
concepts, their various names, and the
relationships among them
• Built from source vocabularies, i.e., thesauri,
classifications, coding systems, and lists of
controlled terms that are developed and
maintained by different organizations
• 476,313 concepts and 1,051,901 different
concept names from >40 source vocabularies
Organization of Metathesaurus
• Organized by concept (meaning)
• Concept unique identifier (CUI) identifier linked to each concept
• String unique identifier (SUI) - identifier
for each unique concept name or string
• Lexical unique identifier (LUI) - links all
lexical variants
Organization of Metathesaurus
Concepts (CUIs)
Terms (LUIs)
Strings (SUIs)
C0004238
Atrial Fibrillation
Atrial Fibrillations
Auricular Fibrillation
Auricular Fibrillations
L0004238
Atrial Fibrillation
Atrial Fibrillations
L0004327
Auricular Fibrillation
Auricular Fibrillations
S0016668
Atrial Fibrillation
S0016669
Atrial Fibrillations
S0016899
Auricular Fibrillation
S0016900
Auricular Fibrillations
Major Use
• Interface - optimized for user data entry
• Administrative - optimized for statistical
classification
• Reference - optimized for nonambiguous concept definition,
information retrieval, and analysis
What is a Concept-Oriented Terminology?
• Focus on concept (unit of thought) rather than
on term (linguistic expression)
• Terminology in which the concepts are formally
represented in a manner that renders them
suitable for computer processing
• Optimized for computer vs. human processing
(understanding)
• Reference terminology as compared to an
interface or administrative terminology
Concept-Oriented
Concept
Symbol
Object
Formal Definition of Concepts
• NOC - Knowledge: Breastfeeding
• Lexical definition
– Extent of understanding conveyed about lactation
and nourishment of infant through breast feeding
• Formal definition
Has component NOC.KNOWLEDGE:BREASTFEEDING
Has property FINDING
Has sample PATIENT/CLIENT
Has timing POINT
Has scale ORDINAL
Has method OBSERVED
Optimized for Computer Processing
• Processing on meaning (semantics) rather
than structure (syntax)
• NOC - Knowledge: Breastfeeding
Has component NOC.KNOWLEDGE:BREASTFEEDING
Has property IMPRESSION
Has sample PATIENT/CLIENT
Has timing POINT
Has scale ORDINAL
Has method OBSERVED
IS-A KNOWLEDGE MEASUREMENT
IS-A BREASTFEEDING MEASUREMENT
What Do We Gain by Building a
Concept-Oriented Terminology?
• Enhanced retrieval of data at varying levels
of abstraction
• Improved ability to aggregate and compare
data across representations
– Mapping from interface to administrative
terminologies
– Mapping among interface terminologies
– Mapping among administrative terminologies
• Version control and terminology evolution
over time
Examples of Concept-Oriented
Terminology Systems
• GALEN
• Logical Observations Identifiers, Names,
and Codes (LOINC)
• Medical Entities Dictionary (The MED)
• SNOMED RT
What Does It Take to Build a
Concept-Oriented Terminology?
• Terms with codes to provide “values”
for concepts in the models
• Terminology model
• Representation language
• Software for processing
Status of Components in Nursing
• Terms with codes to provide “values”
for concepts in the models - many
• Terminology model - evolving
• Representation language - generic
• Software for processing - generic
Terminology Model
• Explicit representation of a system of concepts
that is optimized for terminology management
and that supports the intensional definition of
concepts and the mapping among terminologies
• A terminology model depicts the associative
relationships between an aggregate (molecular)
expression and more primitive (atomic) concepts
• Type definition - attributes (properties, roles)
necessary and sufficient for non-ambiguously
defining a concept of a particular type (fully
specified name)
Example
• Diabetic foot care - Teach
• Type definition for nursing activity
concept
– Action TEACH
– Target DIABETIC FOOT CARE
– Recipient of care PATIENT
Representation Language
• Description logics based on predicate
calculus represented in different formalisms
– Predicate calculus
– Conceptual graphs (e.g., KRSS)
– GRAIL
• Vary in expressibility and parsimony
Software for Processing
• Formal and automated classification (IS-A
relationships) of new concepts
• Inheritance of attributes of parent concepts
to facilitate formal definition of child
concepts
• Rules (grammar) for generation of
composite concepts
• Natural language generation (GALEN)
• Conflict resolution management for
distributed development (SNOMED RT)
Examples
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GALEN
SNOMED RT
GALEN
What Does the Box Need to
‘Know’?
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•
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How to classify things
Sensible combinations
Redundant information
etc...
GRAIL
actsOn
Relieving
Pain
(Relieving which actsOn Pain)
name RelievingPain
GRAIL - Formal Subsumption
actsOn
Relieving
Symptom
Relieving which actsOn Symptom
Pain
Relieving which actsOn Pain
GRAIL - Normalization
Injecting which <
actsOn Medicine
hasMeans Syringe>
Injecting which<
actsOn Medicine>
Injecting which<
actsOn Medicine>
Representing ICNP in GRAIL
Injecting
Interviewing
Treating
Glass eye
Medicine
Person
Hypnosis
Syringe
Mapping to ICNP
NIC
ICNP
2.A.-4.Caring
Tube care:
Gastrointestinal
2.B.-2.1.3.Tubes
2.E.-1.1.13.Gastrointestine
GRAIL - Classification
‘Nursing Interventions
Taking As Object
Other Objects’
‘Nursing Interventions With
Reference To: Anatomical
Locations’
Caring which <
hasPersonPerforming Nurse
actsOn (Tubes which
hasLocation Gastrointestine>
Benefits of Compositional
Approach
• Definitions are made explicit
– Utilizes underlying concepts to manage
model
• Multiple classification
– Supports dynamic reorganization
• Naturalistic language generation
– Hide syntax from users
GRAIL - Language Generation
Caring which <
hasPersonPerforming Nurse
actsOn (Tubes which
hasLocation Gastrointestine>
‘Caring for tube, gastrointestine’
GRAIL - Mediation between
Representations
Symptom
Pain
Acute
pain
Pain which
hasChronicity acute
HHCC
GRAIL
Pain
NANDA
Nursing Intervention
performance
IS MODALITY OF an action
IS PERFORMED BY nurse
person
PLAYS ROLE nurse role
Preoperative Coordination
performance
IS MODALITY OF coordinating
IS PERFORMED BY nurse
OCCURS preoperatively
Bottle Feeding
performance
IS MODALITY OF feeding
IS PERFORMED BY nurse
HAS MEANS bottle
SNOMED RT
• Optimized for retrieval and analysis of
data relating to the causes of disease,
treatments of patients, and outcomes of
the overall health care process
• Based on SNOMED International
• Provider-neutral representations
• Evolving toward SNOMED Clinical Terms
SNOMED RT
• Includes:
– Representation language - modified KRSS
– Computer-based tools (Galapagos,
Ontylog, Metaphrase)
• Missing for nursing:
– Terms with codes to provide “values” for
concepts in the models
– Categorical structures
Representation Language
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
Example: Postoperative esophagitis
SNOMED RT syntax
D30150:
D5-30100 &
( assoc-topography T-56000) &
( assoc-morphology M-40000) &
(assoc-etiology F-06003)
Terminology Model Development
and Validation Efforts
• Nursing activity example
• International Standards Organization
• SNOMED Convergent Terminology
Group for Nursing
• Nursing Terminology Summit
Standardized Terminologies with
Terms for Nursing Activity Concepts
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Nursing Interventions Classification
Home Health Care Classification
Omaha System
Patient Care Data Set
AORN Perioperative Nursing Data Set
SNOMED RT
NHS Clinical Terms
International Classification of Nursing Practice
Study Purpose
• Evaluate the adequacy and utility of a type
definition (required parts of a terminology model)
for nursing activities
• Research Questions
– What percentage of nursing activity terms includes the
attributes of the type definition (Delivery Mode, Activity
Focus, and Recipient)?
– Can the nursing activity terms be reliably decomposed
into the three attributes of the type definition?
Definitions
• Activity - intentional service delivered by a
provider to a recipient (e.g., wound care
provided by a nurse, grief counseling provided
to a family)
Definitions
• Delivery Mode - manner in which the activity is applied
to the recipient (e.g., assess the patient for shortness
of breath, coordinate the delivery of Meals on Wheels)
• Activity Focus - phenomenon upon which the activity
is centered. Activity Focus can be a medical or
nursing diagnosis, sign, symptom, problem or health
issue (e.g., pain, inadequate knowledge)
• Recipient - person, family, organization, or aggregate
to whom the activity is delivered. The patient is the
implicit recipient of all activities unless otherwise
specified (e.g., apply sterile dressings to wound
[patient]; teach the caretaker transferring
precautions)
Data Sets
• Chart terms (Interface)
• Home Health Care Classification
(Interface and Administrative)
• Omaha System (Interface and
Administrative)
Chart Terms
• 1039 non-redundant nursing activity
terms
• Health records of >300 persons
hospitalized for AIDS-related
condition
• Verbatim abstraction
Procedures
• Each nursing activity term decomposed into the
three elements of the type definition
– Delivery mode - identified and coded as Explicit or Implicit
– Recipient - categorized as Explicit, Implicit, or Ambiguous
• Multiple raters - trained on subset with one rater
serving as gold standard
• Coded as containing the three elements of the type
definition if:
– Delivery mode = Explicit
– Activity focus = Present
– Recipient = Non-ambiguous (Implicit or Explicit)
Examples: Chart Terms
• Assess family knowledge
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–
–
–
Delivery mode - Assess (Explicit)
Activity focus - Knowledge level (Present)
Recipient - Family (Explicit)
Contains 3 elements of type definition - Yes
• Notified MD
–
–
–
–
Delivery mode - Notified (Explicit)
Activity focus - Absent
Recipient - MD (Explicit)
Contains 3 elements of type definition - No
• Oxygen administration
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–
–
–
Delivery mode - Administer (Explicit)
Activity focus - Oxygen (Present)
Recipient - Patient (Implicit)
Contains 3 elements of type definition - Yes
Examples: HHCC
• Blood pressure - Assess
–
–
–
–
Delivery mode - Assess (Explicit)
Activity focus - Blood pressure (Present)
Recipient - Patient (Implicit)
Contains 3 elements of type definition - Yes
• Coping support - Teach
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–
–
–
Delivery mode - Teach (Explicit)
Activity focus - Coping support (Present)
Recipient - Patient or Family (Ambiguous)
Contains 3 elements of type definition - No
• Medication administration - Direct care
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–
–
–
Delivery mode - Direct care (Explicit)
Activity focus - Medication administration (Present)
Recipient - Patient (Implicit)
Contains 3 elements of type definition - Yes
Frequencies of Attributes of Type Definitions
Attribute
Chart
HHCC
Omaha
Delivery mode
Explicit
Implicit
Absent
82.0
18.0
0.0
100.0
0.0
0.0
100.0
0.0
0.0
Inter-rater reliability
GS vs. Raters 2 & 3
GS vs. Rater 4
GS vs. Rater 5
94.4
100.0
100.0
Frequencies of Attributes of Type Definitions
Attribute
Chart
HHCC
Omaha
Activity focus
Present
Absent
95.1
4.9
100.0
0.0
100.0
0.0
Inter-rater reliability
GS vs. Raters 2 & 3
GS vs. Rater 4
GS vs. Rater 5
98.7
100.0
100.0
Frequencies of Attributes of Type Definitions
Attribute
Chart
HHCC
Omaha
Recipient
Explicit
Implicit
Ambiguous
19.2
75.9
4.8
13.0
78.3
8.7
1.6
61.9
36.5
Inter-rater reliability
GS vs. Raters 2 & 3
GS vs. Rater 4
GS vs. Rater 5
94.0
88.2
68.9
Discussion
• Majority of chart terms contained elements
of the type definition
– Reliably decomposed
• Type definition had utility as a model for
decomposing HHCC and Omaha
– Activity focus and Delivery mode decomposition
straightforward and easily reproducible
– Recipient more frequently ambiguous than in
chart terms
– Inter-rater reliability lower for recipient
International Standards
Organization (ISO)
• Initially approved as a New Work Item
then resolution made by CEN & ISO to
request re-submission of the New Work
Item Proposal under the Vienna
Agreement 5.1 with an ISO lead
Scope of the Proposal
• This New Work Item will integrate
existing work and work in progress to
establish a nursing terminology model
consistent with the goals and objectives
of other specific health terminology
models and provide a more unified
reference health model.
Structure
• Steering Committee
• Technical Committee
• Expert Committee
Steering Committee
• The Steering Committee is responsible for project
management including the development and
monitoring work processes and timelines.
• Members
– Virginia Saba, EdD, RN, FAAN (Chair of IMIA/NI-SIG & Chair
of the IMIA/NI-SIG Concept Representation Group)
– Evelyn Hovenga, PhD, RN (Outgoing Chair of the IMIA/NISIG)
– Kathleen McCormick, PhD, RN, FAAN (Chair of the Data
Standards Working Group, IMIA/NI-SIG)
– Amy Coenen, PhD, RN, CS (Representative from the ICN and
Director of the ICNP®)
Technical Committee
• Responsible for preparing a draft standard using
input from all participants. Revise the proposal as
needed based on feedback and testing. Members of
this group will be selected by the Steering Committee
and will not exceed one person per country.
• Members
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Suzanne Bakken (USA) (Facilitator)
Kathryn Hannah (ISO Representative, Canada)
Nicholas Hardiker (UK)
Heimar R. Marin (Brazil)
Randi Mortensen (Denmark)
Hyeoun-Ae Park (ISO Representative, Republic of Korea)
Expert Committee
• Responsible for providing input on
standard development and review of
draft proposals.
• This group will include expert
volunteers from ISO and others willing
and interested in participating in the
process.
Terminology Model
• Explicit representation of a system of concepts
that is optimized for terminology management
and that supports the intensional definition of
concepts and the mapping among terminologies
• A terminology model depicts the associative
relationships between an aggregate (molecular)
expression and more primitive (atomic) concepts
Reference Terminology Model
for Nursing Diagnoses
is perspective on
dimension
is applied to
judgement
focus
timing
is applied
to
has site
degree
potentiality
acuity
timing
has subject of information
site
subject of information
Example
• Activities of daily living alteration
–Alteration
• Has potentiality qualifier: Actual
• Is applied to: Activities of daily living
• Has subject of information: Client
Reference Terminology Model
for Nursing Actions
has site
site
action
timing
acts on
has route
has means
target
has subject of care
route
subject of care
means
Example
• Pressure ulcer assessment
–Assessing
•Acts on: pressure ulcer (target)
•Has subject of information: client
(implied)
Conclusions
• ISO standard for a reference
terminology model for nursing will
support the mapping among nursing
terminologies
• Must be integrated within a broader
health care terminology model
SNOMED Convergent Terminology
Group for Nursing
• Members
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SNOMED International Editorial Board Member
SNOMED staff
ANA liaison
CMT nurse modelers
Nurse consultant
• Activities
– Developing and testing models
– Outreach and education
– Collaboration agreements with ANA-recognized
terminology developers
– Participation in standards efforts
Nursing Terminology Summit
• Consensus development
• Think tank
• Constituencies
– Terminology developers
– System implementers
– Standards experts
• Focus
– Reference terminology model
– CEN/ISO
– Clinical templates
Impact of Concept-Oriented
Terminologies
• Medical Entities Dictionary
– Concept-oriented terminology
– Meta-data dictionary for applications at
New York Presbyterian Hospital