HIMSS 2011 Implementation of Standardized Terminologies Survey Results The current healthcare climate, with rising costs and decreased reimbursement, necessitates fiscal responsibility. Elements of the 2010 Health Care Reform Act legislation tie patient safety and quality outcome measures to reimbursement. The health care literature is replete with examples of the need to demonstrate and measure health care safety and quality. With an increased focus on improving health care safety and quality, the use of standardized terminologies generates data needed to continuously improve practice (1). Use of a terminology supports the capability for retrievable of consistent data that can be shared across clinical providers, clinical settings and healthcare specialties. The data is used to assess clinical processes and help quantify safety and quality outcomes. Deploying standardized terminologies for use across the continuum of care is an essential strategy to perform comparable research which can have a positive effect on the quality of patient care. Goal The goal of this survey was to obtain quantifiable data on the implementation of nursing terminologies in various care settings and by various stakeholders. The survey was developed by the HIMSS Nursing Informatics Community Terminology Resources Workgroup: Diane K. Struck, BSN, MS, Workgroup Chair, Christine Corkins, RN, PMP, Catherine Ivory, RNC OB, RN BC, MSN, Cynthia B. Lundberg, RN, BSN and Christel Anderson, HIMSS Director of Clinical Informatics staff liaison. Methodology To gain a better understanding on the implementation of nursing terminologies in various care settings and by nursing professionals, the HIMSS Nursing Informatics Community conducted a Web based survey. Nursing professionals were issued a series of electronic invitations in January and February, 2011. A total of 333 usable responses were received to this survey. Respondents The majority of the 333 nurse professionals who participated in this survey worked in a hospital setting 60% worked at a hospital/multi hospital system/integrated delivery care setting with 40% either seeking or have obtained Magnet status. Approximately 9% of survey respondents worked within an ambulatory care facility, home health care organization or within community and public health. The remainder of survey respondents worked within an academic institution (15%); consulting firm (5%); vendor (4%); or a federal, state, or local government office (2%).
Is There a Terminology in Place? Of the 333 useable responses, 31% (102 respondents) indentified that they currently had a standardized terminology in place. An overwhelming majority 69% (231 respondents) identified that they either did not have a terminology in place or did not know. Q: Do you currently have a nursing terminology implemented within your health information system? Terminologies Currently in Use Of the 102 respondents, 77% identified they currently have one of the following American Nursing Association recognized nursing terminology within their health system: ABC Codes Clinical Care Classification (CCC) International Classification for Nursing Practice (ICNP ) Logical Observation Identifiers Names and Codes (LOINC ) NANDA International Nursing Diagnoses, Definitions, and Classification Nursing Interventions Classification System (NIC) Nursing Minimum Data Set (NMDS) Nursing Outcomes Classification (NOC) PeriOperative Nursing Data Set (PNDS) SNOMED CT The Omaha System Other Interestingly, 23% of the respondents indentified they did not know what type of terminology was in place within their health care organization. The following may explain this result: demographics of respondents including the length of formal education, years of clinical practice, and level of experience. Additionally, the terminology is not visible at the point of care, but
rather a part of the workflow; it is not readily apparent in selection, implementation and build of the system. The remaining 12% of respondents identified they had a combination of terminologies in place. Q: Which terminology/terminologies are currently in use within your organization? Who Uses the Terminology? The majority of respondents (69%) identified that the terminology is most widely used by clinical nurses. Interestingly, several respondents (19%) identified that the terminology was in use enterprise wide by multiple professionals including: Ancillary Services (i.e. Dietary/Nutrition, Lab, OT, PT, Pharmacy, Radiology, and Respiratory Therapy), Clinical Nurses, Medical Technicians / Aides, Physicians and other Care Providers (i.e. Case Management, NPs, PAs, CRNAs, and Social Workers). An assumption can be made that other health care domains may see terminologies approved for use by nursing are intended only for nurses. Rather these terminologies are not unique and proprietary to nursing but are patient centric. As an illustration: pain can be documented by a Physical Therapist, Physician or by a Nurse and therefore only one representation of the concept of pain is required within the standardized terminology that can be used by all clinicians to document that the patient is experiencing pain. In What System is the Terminology Implemented? Respondents were asked to identify if a nursing terminology was implemented in Ancillary, Special Care, Enterprise Wide, or Facility Wide systems. The majority of respondents (44%) identified there was a nursing terminology implemented enterprise wide, as defined to be across multiple facilities/hospitals. The second highest rated area (34%) was facility wide and defined to be across several units in one facility.
Drivers for Adoption While standardized terminologies are used by many disciplines, including nursing, the nursing profession may have the most to gain by implementing standard terminologies. The chart below summarizes survey responses related to key drivers for implementing standardized terminologies. Many inpatient hospital complications such as falls and pressure ulcers have been described as nurse sensitive quality measures. In 2007, Medicare stopped paying for the never events (2). By using standardized terminologies, nurses can begin to correlate nursing interventions with corresponding patient problems and their expected outcomes to potentially validate or refute the relationship of nursing care to patient. Most health systems today are designed to capture data for which a charge may be attached (for example, through ICD codes). Nursing care is reimbursed as part of the daily room or bed charge and is essentially invisible. By accurately and consistently capturing nursing interventions, the work of nursing may be measured and correlated with outcomes. Q: Please identify the drivers for adoption of nursing terminology/terminologies within your organization. Barriers to Implementation The chart below describes respondents perceived barriers to implementing standard terminologies. Interestingly, many respondents indicated that they were unaware standard terminology options existed, or their vendor did not offer a standardized terminology for their implementation. With federal incentive dollars tied to meaningful use of health care information
technology and meaningful use criteria very focused on interoperability and quality data retrieval, a shift in consumer awareness of and vendor support for the use of standard terminologies should be expected. Adoption of use is a barrier to implementation in that the standardized terminologies do not represent a natural language in the point of care description. Q: What are the barriers to successfully implementing nursing terminologies in your organization today? Conclusion The most significant finding was that less than one third (31%) of those surveyed used a nursing terminology in their health system. Survey results indicate a real need to increase the knowledge of standardized terminology within the nursing workforce. Increasing the knowledge can be accomplished through education, training and workforce development. Nurse educators must incorporate standardized terminologies into the nursing curriculum in the academic setting (3). Continuing education should include terminology emphasis so that all nurses can have baseline knowledge of nursing terminology. With increased education, greater adoption of standards will occur enterprise wide. These survey results indicated that nurses surveyed understand the value of terminology with regards to nursing intervention, increasing safety, and compliance with national quality measures allowing greater adherence to standards of care. Future Vision Nursing terminology is essential in Electronic Health Records (EHRs). The previous National Coordinator for Health IT, David Blumenthal stated that EHRs will improve caregivers decisions and patients outcomes (4). The Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments when providers use EHRs to achieve specified improvements in care delivery (4). The key for a successful EHR implementation is for nurse leaders to become engaged in roles that focus on major HIT adoption including meaningful use,
for example by becoming involved in the Federal Health Information Technology Standards Committee. Having a nursing voice at the federal level will help educate members of various committees on the value that nurses bring to patient care outcomes. On the local level, involvement from the whole health care team, especially the entire senior leadership team is necessary to support adoption. As the Robert Wood Johnson Foundation and Institutes of Medicine reported in October 2010, there is an opportunity to transform the United States health care system and nurses can and should play a fundamental role in this transformation (5). Utilizing better data collection and instituting standardized terminologies will have improved health outcomes and patient safety for all. References: 1. Keenan, G., Tschannen D., and Wesley M. Standardized Nursing Terminologies Can Transform Practice. Journal of Nursing Administration 38, 3, 103 106. 2. Department of Health and Human Services. State Medicaid Director. Retrieved from http://www.cms.gov/smdl/downloads/smd073108.pdf 3. Burkhart, L., Sommer S. (2007). Integrating Preventive Care and Nursing Standardized Terminologies in Nursing Education: A Case Study. Journal of Professional Nursing 23, 4, 208 213. 4. Blumenthal D., Tavenner M. The Meaningful Use Regulation for Electronic Health Records. The New England Journal of Medicine; http://healthpolicyandreform.nejm.org/?p=3732 5. Institute of Medicine. The Future of Nursing; Leading Change Advancing Health October 2010 p. 1 8. How to Cite This Report Individuals are encouraged to cite this report and any accompanying graphics in printed matter, publications, or any other medium, as long as the information is attributed to the HIMSS 2011 Implementation of Standardized Terminologies Survey Results. For More Information For more information on this initiative, visit the HIMSS Nursing Informatics Toolbox; explore the HIMSS Nursing Informatics Community website or contact us. ##### About HIMSS HIMSS is a cause based, not for profit organization exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of healthcare. Founded 50 years ago, HIMSS and its related organizations have offices in Chicago, Washington, DC, Brussels, Singapore, Leipzig, and other locations across the United States. HIMSS represents more than 35,000 individual members, of which more than two thirds work in healthcare provider, governmental and not for profit organizations. HIMSS also includes over 520 corporate members and more than 120 not for profit organizations that share
our mission of transforming healthcare through the effective use of information technology and management systems. HIMSS frames and leads healthcare practices and public policy through its content expertise, professional development, and research initiatives designed to promote information and management systems contributions to improving the quality, safety, access, and cost effectiveness of patient care. To learn more about HIMSS and to find out how to join us and our members in advancing our cause, please visit our website at www.himss.org