amia 2002 development evaluation final

8/2/2019 AMIA 2002 Development Evaluation Final

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Nursing Terminology Summit2002 Report to AMIA 1

Development, Evaluation,

and Use of ReferenceTerminology for Nursing

Progress Reportfrom the NursingTerminology

Summit


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Todays Panel Overview of the Summit

The Big Picture: Key Concepts

Developing and Evaluating Models A Domain Concept Model for Findings

Models for Nursing Actions

A Model of the Nursing Process

From Models to Reference Terminology

From Reference Terminology to TerminologySystems

Advances in Commercial Systems

Terminology Systems in Clinical Applications


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Overview of the Summit


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The Nursing Terminology

Summit Annual meetings since 1999

Participants from 5 continents

Diverse expertise and work settings


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Summit Steering

Committee Judy Ozbolt, Chair

Ida Androwich

Suzanne Bakken

Patricia Button

Nicholas Hardiker

Charles Mead Judith Warren

Christine Zingo


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Summit Sponsors NLM

HRSA

AMA

AMIA*

Cerner*

HIMSS

IDX

3M

McKesson*

Siemens*

SNOMED*

*Sponsor in 2002


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Mission of the Nursing

Terminology Summit Promote and support

the development, evaluation, and use

of reference terminology for nursingand

the integration of reference nursingterminology with healthcareapplications and with other healthcareterminological systems


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The Summits Methods of

Work Annual meeting

Intervening collaboration

Think tank for resolving questions,coordinating, setting directions fordevelopment to be done elsewhere

Worldwide scope Expert authority (no formal

authority)


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The Summits Aims Coordinate efforts to develop and

integrate standards that involve formalnursing terminology

Promote collaboration

Disseminate knowledge gained

Take home understanding of how work

done in local setting fits into global effortsto develop, evaluate, integrate, and usereference terminology for nursing


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Collaborative Progress

since 1999 IMIA/ICN proposal to ISO in 2000 Integration of CEN work into ISO work in

2001 Integration of nursing concepts and

nursing leadership into HL7, LOINC Nursing terminology models submitted to

ISO committee in 2002; now a Draft

Standard Use of terminology models to guide

development of terminology in SNOMEDand elsewhere


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Development, Evaluation, and

Use of Reference Terminology:

The Big Picture


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Key Definitions

(ISO CD 17115) Domain Concept Model: set of formal

categories, semantic links, and sanctionsdescribing potential characteristics forrepresenting concepts in a domain

Reference Terminology Model:Domain concept model that is optimisedfor terminology management

Dissection: Systematic representation ofa phrase according to a predefineddomain concept model


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Building on the Models Terminology model: represents

concepts and definitional relationships

Reference terminology: populatesmodel with words representing instancesof concepts and relationships

Terminology system: software to

manipulate concepts and relationships Functions limited to processing terminology

Distinct from application systems with which itinteracts


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Development of Reference

Terminology for Nursing Goal:

Populate models with words representinginstances of the concepts.

Methods: Dissect terms from nursing classifications and

other vocabularies according to models tocreate formal representations.

Create controlled vocabularies from commonexpressions and dissect those expressions.

Integrate formal representations from manysources within standards developingorganizations.


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Evaluation of Reference

Terminology for Nursing Iterative and continual

Test and retest models, expressions,and conceptualizations

Must lead to coherent and growingbody of knowledge


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Potential Functions of a Reference

Terminology System Link interface expressions and statistical

classifications to their formal, referencedefinitions

Generate compositional expressions fromatomic concepts

Map between expressions in different

terminologies and their formalrepresentations in the referenceterminology

Compare and harmonize amongterminologies


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Developing and Evaluatingthe Models

Progress at theSummit,

1999-2002


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Nursing Terminology Summit

2002 Report to AMIA 19

A Domain Concept Modelfor Findings:

Similarities andDifferences amongDiagnoses, Goals,

and Outcomes

Judith J. Warren


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Findings, Outcomes, and GoalsFindings(observation)

O1A O2A

Outcome O1A X O2A

Goal X OE

Goal

Variance

X OE-O2A

O=observation, X=intervention, A=actual, E=expected


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Conclusions Goal is no different from Finding in

the terminology model, but in the

information model Goal differs intiming and mood

Outcome is no different from Findingin the terminology model, but in the

information model Outcome has linksto the baseline value and to theIntervention


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Findings Reference

Terminology Model

Value

Method

Derivation

Dimension

Subject ofInformation Focus

Site


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Nursing Diagnosis Reference

Terminology Model

Dimension


Site

Judgment


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Terminology and

Information Models forNursing Actions:

The Use-CaseApproach toDevelopment and

Testing

Pat Button


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Summit Interventions Group Group has focused on nursing

interventions since initial Summit meetingin 1999.

In 2000, initiated focused work on theharmonization of emerging nursingterminology models with the RIM of HL7: Approach: testing the extent to which the RIM

supports the expression and communicationof nursing actions (interventions), from bothterminological and structural perspectives.


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Goal of the Intervention Team Ensure that the HL7 RIM

supports nursing terminology

and that it provides a foundationfor integrating nursingintervention concepts.


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Objectives Provide feedback to HL7 regarding

the ability of the RIM to:

Express nursing interventions (focus:education)

Express the full range of nursinginterventions in patient education

Express other nursing interventions andpotentially support other disciplinaryinterventions


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Approach Analyze a random selection of

interventions from existing

classification systems for fit withHL7 RIM

Selected Patient Education as

intervention for further action (e.g.use case development)


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Approach Created high level education Use Cases

(N=6)

Validated Education Use Cases based

on expert/group feedback Used Nine-Step Model (Russler, 2001)

to validate HL7-RIMs ability torepresent the intervention (instance

diagrams) Initiated submission process for

Education Use Cases at HL7 PatientCare Committee


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Assumptions Use cases for breast cancer education can

provide an adequately robust test case tounderstand the information model terminology

issues related to nursing interventions.


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Use Case 1 - DevelopEducation Plan

Sequence:1. A literature review is performed to collect current education research and best practices.

2. Research external requirements from organizations like JCAHO, HCFA, FDA, NCI, andlarge volume 3rd party payers.

3. Collect internal policies, requirements, and existing educational materials

4. Research patient education materials prepared by other organizations like the AmericanCancer Society, Oncology Nursing Society or 3rd party payers.

5. Gain agreement if standard terminology will be used.

6. Draft initial template for educational interventions. Include the intervention,method, responsibility, intensity, measurement criteria and an example of

expected outcome.7. Iterative review process with team members.

8. Evaluate compliance with standards.

9. Agreement on final educational plan

10. Link finalized education plan to problem list

11. Provide links from standard plan to education knowledge bases. The links should becontext specific.

12. Review and modify on a regular basis.

Pre conditions:

Breast cancer patients were chosen for the first education standard. An oncology education standards committee was formed

Members include Chief Oncologist, VP of nursing, VP of ancillary services, AdvancedPractice Nurses, Director of the Oncology clinic, manager of the oncology inpatient floor,Director of OR services, Manager of oncology homecare services, Clinical Pharmacists.

Post conditions:

Add to repository of education plans.


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Use Case 1 - Research to Define Best Plan

code

: Breast CancerEducation Plan

moodCode

:Definition

statusCode:New

activity_time

: Any

Procedure

value:Yes, include

in plan or No,

do not include

code

: LiteratureReview --

Oncology

Journal

moodCode

:EventstatusCode

:Completedactivity_time:Any

Evaluates

Reads:1) Literature review done to

collect current educationresearch & best practicesaround breast cancereducation.

2) Research externalrequirements: JCAHO,HCFA, FDA, NCI, &large volume 3rd partypayers.

3)Collect internal policies,requirements, & existingeducational materials

4) Research patienteducation materialsprepared by otherorganizations like theAmerican Cancer

Society, OncologyNursing Society or 3rdparty payers.

typeCode

:Target

Participation

codeCaregiver

Role

typeCode

:Author

Participation

code:Committee

Role

value:Yes, include

in plan or No,

do not include

code

:ExternalRequirements

Review

JCAHO

moodCode

:EventstatusCode

:Completedactivity_time:Any

Repeated for eachreview source forinclusion in theeducation planObservation Observation

code

:InternalPolicies

Review

Educational

Plans

moodCode

:EventstatusCode

:Completedactivity_time

:Any

Observation

value:Yes, include

in plan or No,

do not include

code

:OtherOrganization

Review

American

Cancer Society

moodCode

:EventstatusCode

:Completedactivity_time

:Any

Observation

value:Yes, include

in plan or No,

do not include

EvaluatesEvaluates

Evaluates


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Findings: Four Perspectives Methodology used

Implications for HL7 RIM

HL7 RIM implications for terminologymodeling and domain terminologies

General terminology implications


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Findings: Methodology Effective in helping the group evaluate ability of

the HL7 RIM to represent the data related tobreast cancer education

Modified instance diagrams were easy to learnand read

Required nursing domain knowledge, RIMunderstanding, and systems expertise

Reliable and reproducible process, except:

HL7 RIM itself has been a moving target

Evolving and complex HL7 RIM attributes andvocabulary


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Findings: HL7 RIM Implications forTerminology Modeling and

Domain Terminologies

Terminologies cannot be freestanding -must adhere to the rules of information

model structure Vocabularies are expressed within classes,

subclasses, and attributes

HL7 data types exist for each attribute

Data types are populated by publishedvocabularies and other value sets

HL7 reviews, approves, and registersvocabularies as candidates to populate theRIM


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Findings: HL7 RIM Implications forTerminology Modeling and

Domain Terminologies

Symmetry between definition and

execution Information model simply changes mood

Terminology structure must accommodatethe symmetry of the information model,

and should have a similar mood concept


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Findings:

Terminology Implications Intellectual content of existing

nursing terminologies is robust, but

structure not sufficient to meetinteroperability standards Terms for many of the concepts exist

In some instances terms are too general

Semantic and syntactic relationshipsbetween terms are not defined

Reinforces the Summit work to definereference terminology model for nursing


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Next Steps (1) Model other general categories of

nursing interventions (meta

interventions). Consider use of methodology for

nursing diagnoses and outcomes.

Develop a framework for howexisting nursing terminologies fitinto these models, and the HL7 RIM.


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Next Steps (2)

Determine what data are essential

to support the nursing process andto communicate with otherstakeholders in patient care

What data need to be collected andcommunicated

What level of granularity is appropriate


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An Information Model ofthe Nursing Process

William Goossen


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Purpose: To report on the work of the Summit

working group that dealt with the HL7 RIM model of the nursing

process and

templates for the Braden Scale for risk

of pressure ulcer.


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Nursing process model Find the appropriate classes in the RIM.

Clone the classes under new names torepresent relevant parts of the nursing

process. Relate the classes to one other.

Explain the information model of thenursing process.

Create a template for one aspect of thenursing process, a specific observation, that includes knowledge, terms, and

information and builds upon Harriss and Hellemans work.


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Nursing process model Ongoing work:

Corrected error in mixing process and

structure: making two separate models Activity Diagram of nursing process

Class Diagram of information used in thenursing process.


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Start care process

Set expected outcomes 1 - n

Make observation 1-n

Make meta-observation 1-n

More

observationsneeded?

Needfor

care?

Define activities 1 - n

Implement care 1- n

[Y]

[N]More(meta-)

observations

needed?

[Y]

[N]

[Y]

Define diagnoses 1- n

[Y]

[N]

End care process

Activity Diagram of nursing process


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Class model of the NursingProcess

outcomes:Observation

findings:Observation inferences:Observation

diagnosis:Observationgoal:Observation

planned_interventions:Procedure-Mood

implementation_of_care:Procedure

-MoodAssumed in model, but not

worked out.

Assumed in Modeland worked out.

clinical thinking relationshipleads to are based on

clinical judgementrelationship

gives as result

are determined fromgoal determination to solve

problem relationshipsuggests

tries to solveplan to reach the goals

relationshipgives focus to

tries to achievewhat is done and effects relationshiprequires

describes careare goals metrelationship

need to have description ofto be found in


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Issues

Can RIM be used to model process?

Specializations: add distinctive attributes More clarity on nursing process as

delivery mechanism and nursing processas documentation

Discuss relation with CEN 13606 Justify approach / consistency check /

validation


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From the Models toReference Terminology


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Representing Nursing

Concepts and Relationshipsin SNOMED CT

Deb Konicek


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SNOMED Convergent

Terminology Group for Nursing Composed of members having expertise in:

-terminology development

-creation and evaluation of terminologymodels for nursing concepts

-the dissection (modeling) of nursing terms

using a specific terminology model

SNOMED CT


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SNOMED CTNursing Integration Efforts

Committed to:

-utilizing existing nursing terminologies assource of nursing content

-actively participating in standards work

-striving for consistency with existing models

-evaluating the usefulness of proposed ISO

model for SNOMED CT integration of nursingdiagnostic, intervention,and goals/outcomesconcepts


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Findings Reference

Terminology Model

Value

Method

Dimension


Site

InterpretsSubject ofInformation

Finding Site Method & Scales


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Nursing Diagnosis Reference

Terminology ModelDimension


Site

JudgmentInterprets Has

interpretation

Finding site

Subject ofInformation


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ISO Nursing Diagnosis

ModelNANDA Ineffective Individual Coping

Has focus COPING Interprets:Ability to cope

Has judgment INEFFECTIVE (interpretation)

Has potentiality ACTUAL (context-qualifier)

Has subject of information INDIVIDUAL(soi)

Other components are not applicable


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ISO Nursing InterventionModel

Action

Site

Route

Using

Means

Target

Subject of care

Rootprocedure

Has focus

Recipient of care

Procedure Site

Approach

SNOMED CT N i


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SNOMED CT Nursing:Conclusion

Currently:

-the discussed links,attributes,componentsnecessary for modeling nursing diagnoses &interventions were proposed/accepted bySNOMED Editorial Board

-ISO model provides validation of these efforts

-ISO diagnoses & Vocabulary Summit findingmodels provide future direction for nursingoutcomes modeling initiatives


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From Reference

Terminology toTerminology Systems


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Reference Terminology and

the Next Generation ofSystems:

Advances at Cerner,McKesson, andSiemens

Pat Button


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Overall Industry

Sponsor Perspective Nursing Terminology Summit is:

Worthwhile, positive effort.

Providing significant impact withinindustry and standards organizations.

Valuable forum for networking andaddressing key issues that havechallenged industry for many years.


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McKesson: Horizon Clinicals Clinical reference terminology

strategy:

Reduce customer build times. Share common tools and core

knowledge sets.

Build knowledge-rich applications using

a solid foundation. Support communication within our

clinical product line.


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McKesson:Horizon Clinicals Clinical reference terminology

foundation:

SNOMED CT as a core referenceterminology

LOINC

Evaluation of nursing vocabularies for

inclusion: NANDA, NIC, NOC,International Classification of NursingPractice, etc.


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Siemens: Summit Impact Improved data representation for

nursing concepts through integration

of nursing terminology learnings intodatabase design, middle tierarchitecture, terminology models, &flexible end user interfaces.

Consolidation of existing nursingterminologies into a unifyingreference terminology model.


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Siemens: Summit Impact Engendered increased

understanding of strategic needs &

issues surrounding theimplementation of a broader clinicalterminology solution.

Leveraged opportunities to

communicate, educate, & promotethe work of the Terminology Summitin the healthcare market.


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Cerner Strategy Strategy:

Cerners Information ModelTM Controlled

medical terminology. Executable KnowledgeTM - Provision of

evidence based, executable knowledge that leveragesthe Information ModelTM architecture and structures.


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Cerner Information ModelTM

The Information ModelTM is structured in amanner that can house specificterminology sets and inter-relate them, as

well as provide the flexibility toaccommodate local extensions andpreferences for synonyms.

HLi is Cerners business partner. HLi

provides the meta database and modelingtools to enable Cerner to manage thirdparty terminologies, and Cerner clients tomanage their own nomenclature

extensions.


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Cerner Information ModelTM

Information ModelTM based on SNOMED

CT. Cerner & SNOMED International have

a close working relationship, including

being one of two parties in a pilot program

to test a new terms submissions and

request management process.

Nursing terminologies from a CMTperspective refers to a set of terminologies

for the nursing care process.


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CernerApproach:

Nursing Terminologies Key Points:

Cerner does not endorse any one or several of theANA recognized nursing languages.

Cerner will provide the infrastructure to support theuse of any of the ANA recognized nursinglanguages.

Cerners infrastructure, the Cerner InformationModel, is based on SNOMED CT and leverages themapping SNOMED has completed to various termsfrom the nursing languages.

Current focus: definition of model for all patientcare orders/interventions & outcomes, clinicaldiagnoses and problems to provide basis forintegration of SNOMED CT and definition of dataelements to use in order sets, pathways, plans ofcare.


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Direct Use of Formal

Terminology Systems inClinical Applications:

Difficulties andSolutions

Suzanne Bakkenand Nicholas Hardiker


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Aims (and assumptions) To consider the direct use of formal

terminology systems in clinical

applications Formal terminology systems can play

both a reference role AND an interfacerole

To expose difficulties and inform thedevelopment of solutionsPlug and play is not possible


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Difficulties Direct use is awkward

There is a conflict between the

characteristics of formal terminologysystems...

they must behave in a rigorouslypredictable way

and the needs of users they must be understandable, usable and

fit with routine practice


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Methods - Storyboarding A nurse assesses the nutritional

status of a patient in order to make

a diagnosis Any proposed application should

support this process while allowingthe nurse to document the

assessment, in line with routinepractice, via a formal terminologysystem


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Methods - Use case analysisA System

Present relevant

item for selection

Nurse

M h d S i


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Methods - Scenario

developmentThe application presents a list ofrelevant assessment topics,

including Nutritional assessmentThe application presents through adata entry form a number of

relevant sub-topics such as Mobilityetc


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Methods - PrototypingA system

Nutritional assessment

UnderweightAppearance

Mobility

Weight kg

Overweight

Mobile Immobile

Diagnosis Nutrition Nutrition

M th d A ti it


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Methods - Activity

diagramming

User Interface Dialogue Terminology

Select topicReturn topic Get relevant

item

Return relevant

item

Put relevant

item on form


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Key findings It is difficult to capture the pragmatics of

routine practice within formal terminologysystems

A dialogue sub-system is needed to managethe things traditionally embedded withininterface terminologies clinical knowledge

business rules

There will be a dependency between the userinterface, the dialogue sub-system and theformal terminology system - each will impactthe others


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Messages to Take Home Much has been done to develop and

integrate nursing terminology standards.

Much remains to be done. Evaluation and progress are iterative and

ongoing.

Draft standards and other insights are

already being used to develop tomorrowsapplications.


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Thank you! Questions or comments?

amia 2002 development evaluation final

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