Nursing interoperability is within our grasp!

Feb. 15, 2016 / By Susan Matney, PhD, RN

In July of 2014, I wrote a blog asking if nursing interoperability was within our reach. I wrote that there were gaps in the standard terminologies and the data elements required to document nursing care. Also, at that time, no national standards initiatives expressly stated “nursing.” I’m excited to write this follow-up blog because many things have happened since to leverage the interoperability of nurse-collected data. In this blog, I will describe the additions to the terminology standards (specific to nursing), national nursing standards initiatives and terminology tools for nurses.

The nursing terminology work stems from the University of Minnesota Nursing and Big Data annual conference. The team working on nursing assessments has finalized the observations for a basic medical/surgical physiologic assessment. The most recent LOINC release contains the newly created nursing physiologic assessment panel. The nursing assessment panel constitutes 137 observations (55% new LOINC), and 348 observation values organized into 16 panels (72% new LOINC). This reference set of common nursing assessment data elements encoded to LOINC and SNOMED CT can be used to support the exchange of nursing information, facilitate multi-site research and provide a framework for nursing data analysis.

Three key things within the national standards space have transpired regarding interoperable nurse-collected data:

• The American Nurses Association (ANA) released a position statement recommending that SNOMED CT and LOINC should be used when exchanging a C-CDA with another setting. They also advised each healthcare setting to create a plan for implementing ANA terminologies to support nursing practice.

• The Health Information Management Systems Society (HIMSS) Chief Nursing Officer/Chief Nursing Information Officer (CNO-CNIO) Vendor Roundtable recommended ten Guiding Principles for Big Data in Nursing of which four endorse standards and interoperability. The recommendation promotes standard terminologies and suggests that all care settings create a plan for mapping ANA-recognized nursing terminology to national standards such as SNOMED CT or LOINC.

• The Health IT Interoperability Standards Advisory (ISA) is a roadmap to interoperability shaped by stakeholder input. The Office of the National Coordinator (ONC) identifies the “best available” interoperability standards and implementation specifications for the healthcare industry. The ISA includes standard terminology specifications. In the 2016, The ANA submitted recommendations for nursing interoperability that are included in the 2016 ISA. The document is open for comment, but the current recommendation of the final 2016 Interoperability Standards Advisory includes four new proposed nursing categories: Nursing Assessments, Nursing Outcomes, Nursing Problems and Nursing Interventions & Observations.

These initiatives, coupled with high demand from nursing stakeholders emphasized the need for a resource to facilitate the exchange of health data specific to nursing. Seeing this, the National Library of Medicine (NLM) developed the “Nursing Resources for Standards and Interoperability” web page. The goal of this site is to facilitate interoperability by providing mapping resources using the UMLS. In addition to highlighting valuable resources from NLM, the web page provides detailed information about why particular standards are pertinent and necessary for use in nursing and nursing care documentation. The new web page supports synonymous mappings between SNOMED CT, LOINC and other ANA-recognized terminologies, thus providing a valuable resource for nurses.

Sharable encoded patient data is the key to the development and evolution of nursing knowledge. Terminology content pertinent to nursing, interoperability standards and mapping tools is required to achieve the goal of sharable, comparable data. This is exciting times for nursing interoperable nursing data is within our grasp!

Susan Matney, PhD, RN, FAAN, is a medical informaticist with 3M Health Information Systems, Healthcare Data Dictionary (HDD) Team.