Standardized nursing terminologies come of age: advancing quality of care, population health, and health equity across the care continuum

With the advent of computerization in healthcare, sustained efforts to develop standardized nursing terminologies (SNTs) since the 1970s have enabled nursing assessments and care to be included in electronic health records (EHRs) as a reliable and valid means to determine the contribution of nursing care to patient outcomes. In 1986, Werley et al¹ published the Nursing Minimum Data Set that delineated the information needed about each patient, including demographic elements, nursing care elements (nursing diagnoses, nursing interventions, nursing outcomes, nursing care intensity), and service elements (eg, admission/discharge dates, disposition). Over the subsequent decades, SNTs were developed and refined for nursing diagnoses, nursing interventions, patient goals, and nursing outcomes to capture the process of nursing care and its outcomes for practice, research, and policy purposes.^2–6 The Nursing Minimum Data Set was designed for inclusion in what Werley and Grier had earlier conceptualized as a nursing information system⁷ and the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice recognized nursing classification systems to the National Library of Medicine for inclusion in the Unified Medical Language System in 1994.⁸

Heightened emphasis on formal computable representations of nursing data for use in electronic clinical systems as well as integration into reference terminologies for nursing (eg, International Classification of Nursing Practice) and for the domain of health care (eg, Systemized Nomenclature of Medicine—Clinical Terms [SNOMED CT] and Logical Identifiers Names and Codes [LOINC]) occurred in the late 1990s.^9–11 An international standard for the representation of nursing diagnoses and interventions was approved by the International Organization for Standards in 2003 as the result of a collaborative effort between the International Council of Nursing and the Nursing Informatics Working Group of the International Medical Informatics Association and was revised in 2014.^12,13 In the subsequent decades, the developers of SNTs have continued to refine terminology content and facilitate the integration of SNT into a variety of electronic clinical systems including vendor-developed EHRs.

Over time, there has also been substantial research conducted through secondary analysis of SNT from nurses’ documentation from EHRs to advance nursing knowledge. Concurrently, there have been tremendous efforts at the federal level in the United States and internationally through standards development organizations toward the goal of semantic interoperability with active nursing involvement (eg, clinical information models, clinical document architecture, EHR archetypes, Health Level 7^®’s [HL7] Fast Healthcare Interoperability Resources [FHIR^®] apps).

The Journal of the American Medical Informatics Association (JAMIA) has been a premier venue for reporting on these topics since its initial issue in 1994.¹⁴ Over nearly 30 years, SNTs have matured and the processes for integration into electronic clinical systems have been shown to be valid and reliable. Furthermore, the National Academy of Medicine’s Future of Nursing 2020 to 2030 report explicitly addressed the need for nursing expertise in designing, generating, analyzing, and applying data to support initiatives focused on social determinants of health (SDOH) and health equity.¹⁵ The infrastructure for this important work lies in SNTs, as nurses in their efforts to provide holistic care use SNTs to assess and identify SDOH and select and deliver interventions that address those determinants.

The time is right for JAMIA to publish a focus issue on the role of SNTs and supporting semantic interoperability standards in advancing quality of care, population health, and health equity across the care continuum given the progress in the implementation of SNTs in real-world settings. We hope that the issue will provide an update for those familiar with SNTs, and for those without familiarity will offer an introduction to the role of SNTs in the broader context of semantic interoperability.

Among the 15 papers in this focus issue, 3 have international authors representing 5 countries,^16–18 6 include a focus on SDOH,^18–23 7 utilize large data sets,^{17,19,21,22,24–26} and 5 address clinical decision support (CDS) or precision nursing.^{16,17,25–27} All papers consider 1 or more aspects of interoperability,^16–30 with most focused on the terminology level. The terminologies studied include Clinical Care Classification,²⁹ International Classification of Nursing Practice,^17,18,29 NANDA International,^16,23,27,29 Nursing Intervention Classification,^16,23,27,29 Nursing Outcomes Classification,^16,23,27,29 Omaha System,^{19–22,25,26,29} as well as interdisciplinary terminologies (SNOMED CT,¹⁸ Outcome and Assessment Information System,²⁴ and LOINC¹⁷). In terms of other aspects of standardization, 1 paper explicitly examined the role of ontologies²⁸ and another the role of SNTs in the FHIR standard.²⁹ The paper describing the Friends of the National Library of Medicine (FNLM) workshop in honor of Dr. Virginia K. Saba, nursing informatics pioneer and developer of the Clinical Care Classification⁶ provides a vision and recommendations for the future.³⁰ In the following paragraphs, we highlight 5 papers from the focus issue.

Using structured and unstructured data from a variety of sources including the Outcome and Assessment Information System, Song et al²⁴ applied dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of home health care risk factors. They found patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization of Emergency Department (ED) visit than patients with no documented risk factors. These findings, if incorporated within early warning systems in EHRs, may activate interventions to prevent costly hospitalizations or ED visits.

Umberfield et al²⁸ called for expressing validated nursing theories in formal ontologies to serve not only nursing but also investigators from other domains, clinical information system developers, and the users of advanced technologies such as artificial intelligence that seek to learn from the real-world data and evidence generated by nurses and others.

In the context of climate change and nursing work related to disaster management and climate change, Lokmic-Tomkins et al¹⁸ mapped the United Nations Office for Disaster Risk Reduction and International Science Council (UNDRR-ISC) Hazard Information Profiles to SNOMED CT, which includes terms from the International Classification of Nursing Practice, to determine the extent of clinical terminologies available to capture disaster-related events. They found variable representation of important concepts such as chemical and biological disaster hazard concepts had better representation than meteorological, hydrological, extraterrestrial, geohazards, environmental, technical, and societal hazards, while heatwave, drought and geographically unique disaster hazards were not found in SNOMED CT. These codes will be critical for aiding in disaster preparedness, response, and recovery efforts by nurses and other health professionals.

Cho et al¹⁷ investigated whether SNTs such as International Classification of Nursing Practice and LOINC can support semantic interoperability and outcome tracking over time by implementing an AI-powered CDS tool for fall prevention across 3 tertiary academic hospitals and 1 public hospital with different EHR systems and nursing terms. They found nursing process data contributed markedly to fall-risk predictions, paving the way for further large-scale studies using SNT data to improve healthcare outcomes.

Finally, the guest associate editors delved into the potential synergy and applications of HL7 FHIR^® with SNTs in describing assessments and interventions and measuring outcomes in health care.²⁹ This article aims to improve understanding of how FHIR works to transport and store knowledge and how SNTs work to convey meaning, with recommendations for the next steps to advance FHIR-SNT collaboration.

These JAMIA articles provide glimpses into the myriad solutions SNTs offer to the knowledge representation problems in healthcare, repeatedly demonstrate the leading-edge methods employed with large datasets for nursing care quality and outcomes, and remind us of the relevance, and indeed, the critical need to accelerate employing, using, and advancing SNTs in practice, education, and research going forward. As stated in the reflections from the FNLM workshop honoring Dr. Virginia K. Saba, “let us work together to extend and expand the benefits of nursing terminologies to create the lasting impact that nursing informatics pioneers envisioned.”³⁰

Author contributions

All authors contributed to the drafting of the editorial and approved the final submission.

Conflict of interest

None declared.

References