NURSING INFORMATICS

Informatics Theory

GROUP 2 A-201N
Cruz, Dannelle Mayer Deanon, Marimel Fabula, Francis Kenneth Gabriel, Camille Garino, Krisha Aimon Gambon, Gerlayn

INFORMATICS THEORY
Chapter 17: Theories, Models and Frameworks Chapter 18: Advanced Terminology System Chapter 19: Implementing and Upgrading Clinical Information

Theories, Models and Frameworks

chapter 17

Foundational Documents Guide Nursing Informatics

2001- American Nurses Association (ANA) published the Code of Ethics for Nurses with Interpretative Statements, a complete revision of previous ethics provisions and interpretative statements that guide all nurses in practice, be it in the domains of direct patient care, education administration, or research. Nurses working in the informatics specialty are professionally bound to follow these provisions.

Foundational Documents Guide Nursing Informatics

2003- Nursings Social Policy Statement, Second Edition, provided a new definition of nursing: Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations.

Foundational Documents Guide Nursing Informatics

2004- Nursing: Scope and Standards of Practice, reinforces the recognition of nursing as a cognitive profession. This cognitive work begins with the critical thinking and decision-making components of the nursing process that occur before nursing action begin.

Informatics and Healthcare Informatics

INFORMATICS A science that combines a domain science, computer science, information science and cognitive science. A multidisciplinary science drawing from varied theories and knowledge applications.

Informatics and Healthcare Informatics

HEALTHCARE INFORMATICS Integration of healthcare sciences, computer science and cognitive science to assist in the management of healthcare information. A subdiscipline of informatics Addresses the study and management of healthcare information

NURSING INFORMATICS
Nursing Informatics is the use of information technologies in relation to any nursing functions and actions of nurses. (Kathryn Hannah, 1985)

NURSING INFORMATICS
Nursing Informatics is a combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care. (Graves and Corcoran, 1989)

NURSING INFORMATICS
Nursing Informatics is a specialty that integrates nursing science, computer science and information science to manage and communicate data, information and knowledge in nursing practice. It facilitates the integration of data, information and knowledge to support patients, nurses and other providers in their decisionmaking in all roles and settings. (ANA, 2001)

Nursing Informatics as a Specialty

1992- the ANA established Nursing Informatics as a distinct specialty in nursing with a distinct body of knowledge It provides official recognition that nursing informatics is indeed part of nursing and that it has a distinct scope of practice.

Scope of Nursing Informatics Practice

Developing and evaluating applications, tools, processes and strategies Decision-making Client care Research Education administration

Scope of Nursing Informatics Practice

Information handling Managing data Managing information Managing knowledge Naming Organizing Grouping Collecting Processing

 Analyzing Storing Retrieving Transforming Communicating data and information

Core Phenomena of Nursing and Nursing Informatics

Nursing Nurse Patient Health Environment Nursing Informatics Nurse Patient Health Environment Decision-making Data information Knowledge Information structures Technologies

Models for Nursing Informatics

What is a model? Is a representation of some aspect of the real world Shows particular perspectives of a selected aspect and may illustrate relationships Evolves as knowledge about a selected aspect changes and are dependent on the world view

Graves and Corcorans Model

Placed data, information and knowledge in sequential boxes with one-way arrows pointing from data to information to knowledge. The management processing box is directly above, with arrows pointing in one direction from management processing to each of the three boxes. A direct depiction of the definition of nursing informatics

Graves and Corcorans Model

Management processing

Patricia Schwirians Model

A model of nursing informatics intended to stimulate and guide systematic research in this discipline Concerned about the sparse volume of research literature in nursing informatics Provides a framework for identifying significant information needs which in turn can foster research

Patricia Schwirians Model

Goal and Objective

Technology (Computer system)

Raw material (Nursing related information)

Users (Nurses, students and context)

Turleys Model
The three core components of nursing informatics (cognitive science, information science and computer science) are depicted as intersecting circles.

Turleys Model

Cognitive science

Information Science

Computer Science

Data, Information and Knowledge

These are identified as current metastructures or overarching concepts for nursing informatics with specific definitions in the Scope and Standards of Nursing Informatics Practice.

Data, Information and Knowledge

DATA Discrete entities that are described objectively without interpretation For example, a systolic blood pressure is a datum. Another datum may be a nursing intervention, a patient problem or an outcome.

Data, Information and Knowledge

INFORMATION Reflects the interpretation, organization or structuring of data. The result of processing data Data processing occurs when raw facts are transformed through the application of context to give those facts meaning or via the organization of data into a structure that connotes meaning.

Data, Information and Knowledge

KNOWLEDGE Emerged from the transformation of information Information that is synthesized so that relationships are identified and formalized.

Data, Information and Knowledge

Knowledge
Information

Data

Registered Nurses as Knowledge Workers

Registered nurses are consummate twenty-first century knowledge workers. Their skills in assessment, planning, critical thinking and evaluation are transferrable to many different settings but are most exquisitely employed to nursing practice. Knowledge work depends on access to data, information and knowledge.

Registered Nurses as Knowledge Workers

Atomic level data Foundation for the transforming process by which knowledge work is accomplished. Raw, uninterpreted facts with values and cannot be further subdivided. Analysis, combination, aggregation and summarization are ways in which an information system can transform atomic level data to information and knowledge.

Competencies (Benners)
NOVICE As students, most individuals can be described as novices having no experiences with the situations and related content in those situations where they are expected to perform tasks.

Competencies (Benners)
ADVANCED BEGINNER Advanced beginner can marginally demonstrate acceptable performance having built on lessons learned in their expanding experience base. At this level, individuals often need oversight by teachers or experienced colleagues to help structure the learning experience and support appropriate and successful workplace decision-making and action.

Competencies (Benners)
PROFICIENT Increased proficiency over time results in enhanced competencies reflecting mastery and the ability to cope with and manage competencies. It involves continued practice, combined with additional professional experience and knowledge.

Competencies (Benners)
EXPERT The expert has developed the capacity to intuitively understand the situation and immediately target the problem with minimal effort or problem solving.

Electronic Health Record (EHR)

A client health record supported by computer, electronic and communications technology. Initially, it emerged as a computerbased patient record or CPR. Other terms: Electronic Medical Record (EMR), Electronic Patient Record (EPR), Computerized medical Record (CMR)

Electronic Health Record (EHR)

Any information related to the past, present or future physical/ mental health or condition of an individual. The information resides in electronic system used to capture, transmit, receive, store, retrieve, link and manipulate multimedia data for the primary purpose of providing healthcare and health related services. (American Society for Testing Material, 2004)

Terminologies
Nursing Minimum Data Set (NMDS) by Dr. Harriet Wesley Considered the foundational work for nursing languages and represents first attempt to standardized the collection of essential nursing data. Contains 16 elements divided into patient, service and nursing care elements.

Terminologies
Nursing Minimum Data Set (NMDS) by Dr. Harriet Wesley Nursing care elements include nursing diagnosis, nursing intervention, nursing outcome and intensity of nursing care Patient or client demographic elements address personal identification, date of birth, gender, race and residence.

Terminologies
Nursing Minimum Data Set (NMDS) by Dr. Harriet Wesley Seven service elements include unique facility or service agency number, unique health record number of patient or client, unique number of principal registered nurse provider, episode admission or encounter data, discharge or termination date, disposition of patient or client and expected payer.

Terminologies
Nursing terminologies- offer systematic, standardized ways of describing nursing practice and include data sets, taxonomies, nomenclatures and classification systems. Nomenclatures- are terms or labels for describing concepts in nursing such as diagnosis, interventions and outcomes.

Terminologies
Classifications- are ordering of entities, including nomenclatures into groups or classes on the basis of their similarities. Taxonomy- is the study of classification and simultaneously refers to the end product of classification. Vocabulary- is a set of words label for naming concepts.

Terminologies
NANDA-I Includes 167 recognized diagnoses that are very different from the pathology and mortality focus of the ICD-9 CM terms used for medicine and third party payment claims.

Terminologies
Nursing Interventions Classifications (NIC) It contains 514 nursing interventions that describe the treatments nurses perform, update linkages with NANDA diagnoses, and core interventions identified for 44 specialty practice areas.

Terminologies
Nursing Outcome Classification (NOC) Latest edition of NOC has 33 researched-based outcomes to provide standardization of expected patient, caregiver, family and community outcomes for measuring the effect of nursing interventions.

Terminologies
Client Care Classification (CCC) It is a researched-based nomenclature designed to standardize the terminologies for documenting nursing care in all clinical care settings.

Terminologies
Omaha System It includes assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme) and an outcome component (Problem Rating Scale for Outcomes).

Terminologies
Perioperative Nursing Data Set (PNDS) It provides a universal language for perioperative nursing practice and education and a framework to standardize documentation. It can be used in all perioperative settings and has been integrated into numerous commercial information systems for the operating room environment.

Terminologies
SNOMED CT It is a core clinical terminology containing over 357,000 healthcare concepts with unique meanings and formal logic-based definitions organized into multiple hierarchies..

Terminologies
ABC Codes It provides a mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims. It includes complementary and alternative medicine interventions and codes that map all NIC, CCC, and Omaha systems interventions.

Terminologies
Patient Care Data Set (PCDS) Includes terms and codes for patient problems, therapeutic goals and patient care orders. This data set was developed by Dr. Judith Ozbolt form research data from nine acute care hospitals throughout United States.

Terminologies
Logical Observation Identifiers Names and Codes (LOINC) It is a database of standardized laboratory terms for results reporting for chemistry, hematology, serology, microbiology and toxicology. Now, it includes about 32,000 terms including clinical portion with codes for observations at key stages of the nursing process, including assessments, goals and outcomes.

Terminologies
International Classification for Nursing Practice (ICNP) It is a combinatorial terminology for nursing practice which includes nursing phenomena (nursing diagnosis), nursing actions (nursing interventions), and nursing outcomes.

Terminologies
Nursing Management Minimum Data Set (NMMDS) Includes terms to describe the context and environment of nursing practice, and includes terms for nursing delivery unit/ service, patient/ client population, care delivery method, personnel characteristics and financial resources.

Organizations as Resources
American Medical Informatics Association (AMIA) An individual membership organization dedicated to the development and application of medical informatics in the support of patient care, teaching, research and healthcare administration. An authoritative body in the field of medical informatics and frequently represents the United States in the informational arena of medical informatics.

Organizations as Resources
Healthcare Information and Management Systems Society Responsible for developing many of todays key innovations in healthcare delivery and administration including telehealth, CPRs or EHRs, community health information networks and portable/ wireless healthcare computing. Has special interest groups, local and state chapters, a fellows recognition program, and the recently established professional credentialing service.

Organizations as Resources
National League for Nursing Mission is to advance quality nursing education that prepares the nursing workforce to meet the needs of diverse populations in an ever-changing healthcare environment. Promotes the effective use of technology in nursing education, both as a teaching tool and as an outcome for student and faculty learning, and to advance the integration of information management.

Organizations as Resources
Society for Health Systems (SHS) An individual membership organization that exists to enhance the career development and continuing education of professionals who use industrial and management engineering expertise for productivity and quality improvement in the healthcare industry.

Organizations as Resources
Association for Computing Machinery Became a major force in advancing skills of information technology professionals and students worldwide.

Organizations as Resources
ARMA International Not for profit association serving more than 10000 information management professionals in the United States Canada and over 30 other nations. It includes records and information managers, archivists, corporate librarians, imaging specialist, legal professionals, knowledge managers, consultants, educators, and health care professionals.

Organizations as Resources
ARMA International Mission is to provide education, research, and networking opportunity to information professionals to enable them to use their skills and experience to leverage the value of records, information, and knowledge as corporate assets and contributors to organizational success.

Organizations as Resources
American Society for Information Science and Technology It is the society for information professionals leading the search for new and better theories, techniques and technologies to improve access to information.

Advanced Terminology Systems

chapter 18

Vocabulary Problem The failure to achieve a single, integrated terminology with broad coverage of the healthcare domain. Concept-Oriented Approaches Is the involving criterion for healthcare terminologies for implementation in computer based systems to support the data needs of todays complex, knowledgedriver healthcare, and health management environment.

What this Chapter Focuses on?

Providing the background necessary to understand recent approaches to solving the vocabulary problem Several illustrative examples of these approaches from the nursing domain.

Background and Definition

The primary motivation for standardized terms in nursing is the need for valid, comparable data that can be used information system applications to support clinical decision making and the evaluation of processes and outcomes of care.

Background and Definition

Secondary uses of the data for purposes such as clinical research, development of practice-based nursing knowledge, and generation of healthcare policy are dependent on the initial collection and representation of the data. Given the importance of standardized terminology, one might ask, why, despite the extensive work to date, is the vocabulary problem not yet solved?

The Vocabulary Problem

Several reasons for the Vocabulary Problem which have been posited in Health and Nursing informatics Literature Development of multiple specialized terminologies has resulted in areas of overlapping content, areas for which no content exists and large numbers of codes and terms. (Chute, Cohn & Campbell, 1998; Cimino 1998a)

The Vocabulary Problem

Existing Terminologies are most often developed to provide sets of terms and definitions of concepts for human interpretation, with computer interpretation as only a secondary goal. (Rossi Mori, Consorti & Galeazzi, 1998) The latter is particularly true for nursing terminologies that have been designed for direct use by nurses in the course of clinical care. (Johnson et al.,2003; Martin and Sheet, 1992; Saba and Zukerman, 1992)

The Vocabulary Problem

Unfortunately, knowledge that is eminently understandable to humans is often confusing, ambiguous or opaque to computers, and consequently, current efforts have often resulted in terminologies that are, inadequate in meeting the data needs of todays healthcare system. NOTE: The word terminology is used throughout this chapter to refer to the set of terms representing a system of concepts.

Concepts Orientation
An appreciation for the approaches discussed in this chapter has as a prerequisite an understanding of what it means for a terminology to conceptoriented. The health Informatics literature provides an involving framework that enumerates the criteria (18.1) that render health care terminologies suitable for implementation in computer-based systems.

Concepts Orientation
In particular, it is clear that such terminologies must be conceptoriented (with explicit semantics) rather than based on surface linguistics. (Chute, Cohn & Campbell, 1998; Cimino, 1998b; Cimino et. Al,. 1989) Several studies have reported that existing nursing terminologies do not meet the criteria related to concept orientation. ( Henry & Mead, 1997; Henry et al., 1998)

Concepts Orientation
In order to appreciate the significance of concept-oriented approaches. It is important to first understand the definitions & relationship among things in the world (object), our thoughts about things in the world (concepts), and the labels we use to represent and communicate our thoughts about things in the world (terms). These relationships are depicted by a model commonly called the semiotic triangle (Fig. 18.1) (Ogden & Richards, 1923).

The International Organization for Standardization (ISO) International Standard ISO 1087-1:200

Provider definitions for elements that corresponds to each vertex of the triangle.

 Concept (i.e., thought or reference): unit knowledge created by a unique combination of characteristics is an obstruction of a property of an object or set of object.
Object (i.e., referent): anything perceivable or conceivable

 Term (i.e., symbol): Verbal designation of a general concept in a specific subject field a general concept corresponds to two or more objects which form a group by a reason of common properties (International Organization for Standardization, 1990) As specified by the criteria in table 18.1 and illustrated in Fig. 18.1, a single concept maybe associated with multiple terms (synonym) however, a term should represent only the concept.

Components of Advanced Terminology System

Within the context of the high-level information model provided by the Nursing Minimum Data Set (NMDS) (Werley & Lang, 1988), there has been extensive development & retirement of terminologies for describing patient problems, nursing intervention, & nursing- sensitive patients outcomes. (Johnson, Maas, & Moorhead,2000; Martin and Scheet,1992;Mc Closkey & Bullchek,2000;North American Nursing Diagnosis Association,2003;Ozbolt,1998;Saba,2002), including the development of the International Classification for Nursing Practice (ICNP) Coenen 2003

Concept-Oriented Terminology Model or Ontology

The main components of more advanced terminology systems representing a set of concepts and their interrelationships. The model is constructed using an ontology language that may be implemented using description logic within a software system or a by a suite of software tools.

Terminology System
Is a concept based representation of a collection of domain-specific terms that is optimized for the management of terminological definitions? It compasses both schemata & type definitions (Campbell et. Al., 1998; Sowa, 1984)

Schemata
Incorporate domain-specific knowledge about the typical constellations of entities, attributes and events in the real world and as such, reflect plausible combinations of concepts, e.g., dyspnea may be combined with severe to make severe dyspnea . May be supported by either formal or informal compositions rules (i.e. Grammars)

Type Definitions
Are obligatory conditions that state only the essential properties of a concepts (Sowa, 1984), e.g., a nursing activity must have an recipient, an action, and a target.

Representation Language
Terminology models maybe formulated and elucidated in an ontology language (e.g., GALEN Representation & Integration Language GRAIL ) (Rector et al., 1997) Knowledge Representation Specifications Syntax (KRSS) (Campbell et al., 1998) Web Ontology Language (OWL) (Rector 2004)

Ontology Languages
Represents Classes (also referred to as concepts, categories or types) and their properties (also referred to as relations, slots, roles or attributes.)
In this way, ontology languages are able to support, through explicit semantics, the formal definitions of concepts in terms in of their relationships with other concepts (18.2).

Ontology Languages
They also facilitate reasoning about those concepts, e.g., whether two concepts are equivalent or whether one concepts, such as pain, subsumes (is generalization of) another, such as acute pain.

Computer-Based Tools
A representation language may be implemented using description logic within a software system or by a suite of software tools.

Computer-Based Tools
The functionality of these tools varies but may include among the other things
Management Internal Organization of the model Reasoning on the model, such as automatic classification of composed concepts based on their formal definition e.g., medication teaching is a kind of teaching

Computer-Based Tools
In addition, the software may facilitate transformation of concepts representations into canonical form (e.g., cardiomegaly of the heart is transformed to cardiomegaly since the locations of the pathophysiology is inherent in the concepts itself)

Computer-Based Tools
Or supports a set of sanctions (i.e., constraints) that test whether a proposed composed concept is sensible (e.g., decubitus ulcer of the heart & impaired normal cognition are not coherent terms)

Computer-Based Tools
Other software support may be provided for knowledge engineering, operations management and conflict detection and resolutions.
The extent to which a terminology may be suitable for computer processing has been characterized in terms of GENERATIONS (Rossi Mori , Consorti & Galeazzi, 1998)

1st Generation Terminology Systems

Consists of a list of enumerated terms, possibly arranged as a single hierarchy. They save a single purpose or a group of closely related purposes and allowed minimal computer processing

2nd Generation Terminology Model

Include an abstract terminology model or terminology model schemata that describes the organizations of the main categories used in a particular terminology or set of terminologies.

2nd Generation Terminology Model

Abstract Terminology System Is complemented by a treasures of elementary descriptors (i.e., terms) and templates or rules (i.e., grammar) for defining how categories may be combined. EXAMPLE: pain & severe may be combined into severe pain Second Generation System can be used for a range of purposes, but they allow only limited computer processing, (e.g., automatic classification of composed concepts is not possible).

3rd Generation System

Support sufficient formalisms to enable computer-based processing, i.e., they include a grammar that defines the rules for automated generation and classification of new concepts.

3rd Generation Language System

Are also referred to as formal concepts representation systems ( ingererf,1995) or reference terminologies (Spackman, Campbell, & Cote 1997) The majority of existing nursing terminologies (e.g., NANDA, Nursing Intervention Classifications NIC) can be characterized as a 1st. generation. The beta two version of the ICNP is an example of a 2nd. Generation system (International Council of Nurses,2001)

Advantages of Advanced Terminology Systems

Computer Based System That support clinical uses such as electronic health records and decision support require more granular (i.e., less abstract) data than that typically contained in terminologies designed primarily for manual use or for the purpose of classification ( Campbell et al., 1997, Chute et al., 1996, Cimino 1998b, Cimino et al., 1989)

Advantages of Advanced Terminology Systems

Advanced Concepts-Oriented Terminology System Allow much greater granularity through controlled composition, while avoiding a combinatorial explosion of pre-coordinated terms.

Advantages of Advanced Terminology Systems

Advanced Terminology System Facilitate two (2) important face of knowledge representation for computer-based system that support clinical care: Describing concepts Manipulating and reasoning about those concepts using computer-based tools.

Advantages resulting from the 1st. facet include: Non ambiguous representation of concepts Facilitation of data abstraction or deabstraction without loss of original data (i.e., lossless data transformation) Non ambiguous mapping among terminologies Data reuse in a different context These advantages are particularly important for clinical uses of the terminology

Advantages Gained from the 2nd. Generation facet includes: Automated classification of new concepts An ability to support multiple inheritance of defining characteristics (e.g., acute postoperative pain is both a pain and a postoperative symptoms)

 Both facet are vital to the maintenance of the terminology itself as well as to the ability to subsequent support the clinical utility of the terminology (Campbell et al., 1998; Rector et al., 1997)

Advanced Terminology Approaches in Nursing

Three initiatives that support the development of advanced concept-oriented terminology system for the nursing domain includes: ISO 18104: 2003 GALEN PROJECT SNOMED A nursing term is represented under GALEN & SNOMED approaches in order to illustrate similarities and differences between representations.

 ISO 18104: 2003 An international Standard (ISO 18104: 2003) covering reference terminology models for nursing diagnoses (18.3) and nursing actions (fig. 18.4) was approved in 2003 ( International Organization for Standardization, 2003) The model built on work originating within the European Committee for Standardization ( European Committee for Standardization, 2000)

 ISO 18104: 2003 The standard was developed by a group of experts within ISO technical Committee 215 ( Health Informatics ) Working Group 3 ( Health Concepts Representation) under the collaborative leadership of the International Medical Informatics Association-Nursing Special Interest Group (IMIA-NI) and the International Council of Nurses (ICN)

 Incentives in the Development of ISO 18104: 2003 was

To harmonize the plethora of nursing terminologies in use around the world (Hardiker, 2004) To integrate with other involving terminology and information model standards-the development of ISO 18104: 2003 was intended to be consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model. ( International Organization for Standardization, 2003,p.1)

Potential Uses Identified for the Terminology models Include to:

1. Facilitate the representation of nursing diagnosis and nursing actions concepts and their relationships in a manner suitable for computer processing. 2. Provide a framework for the generation of compositional expressions from the atomic concepts within a reference terminology.

Potential Uses Identified for the Terminology models Include to:

3. Facilitate the mapping among nursing diagnosis and nursing actions concepts from various terminologies. 4. Enable the systematic evaluation of terminologies and associated terminology models for purposes of harmonization 5. Provide language to describe the structure of nursing diagnosis and nursing action concepts in order to enable appropriate integration with information models (ISO)

The standard is not intended to be of direct benefit to practicing nurses. It is intended to be used to those that develop coding system, terminologies, terminology models from other domains, health information models, information system, and software for natural language processing, and make-up standards for representation of healthcare documents.

 ISO 18104: 2003 has undergone substantial bench testing, both during its development and through more recent independent research (Hwang,Cimino & Bakken 2003; Moss, Coenen & Mills, 2003) However, these is an outstanding need for further evaluation in terms of practical application and utility ( Haniker, Casey 2000)

GALEN A concept-oriented approach has been developed within the GALEN Program. Galen can be used in a range of ways: From directly supporting clinical applications (Kirby & Rector, 1996) To supporting the authoring, maintenance and quality assurance of other kinds of terminologies (Rogers et al., 1998)

GRAIL Is an ontology language for representing concepts and their interrelationships the source material for the construction of terminology models (Rector et al., 1997)

Integrated sets of Tools used in the development of a GRAIL model A Computer-based modeling environment Terminology Server
Modeling Environment Facilitates the collaborative formulation of models. It allows authoring of clinical knowledge at different levels of abstraction

Terminology Server Is a software system that implements GRAIL It performs a range of functions including: Internally managing and representing the model Testing the validity of combinations of concepts Constructing valid composed concepts Transforming composed concepts into canonical form Automatically classifying composed concepts into the hierarchy

 The terminology server is also used to deliver the model for use by clinical applications and other kinds of authoring environments GALEN has been applied successfully in other areas of healthcare ( Kirby & Rector, 1996) Two Factors/Motivation for applying GALEN to nursing was: The desire to meet the requirements of users of clinical applications ( Healthfield et al., 1994) The need to provide a reusable and extensible model of nursing terminology

 It is important to recognize that GALEN does not seek to replace existing nursing terminologies; rather it seeks to contribute to the development of those terminologies, to supplements them, to allow comparisons among them and to make them available for describing day to day nursing care.

SNOMED RT Is a reference terminology optimized for clinical data retrieval and analysis ( Spackman, Campbell and Cofe 1997) Concepts and Relationships in SNOMED RT Are represented using modified KRSS rather than GRAIL ( Campbell, et al.. 1998)

Concepts definition and Manipulation are supported through set of tools with functionality such as: Acronym resolution, word completion term completion, spelling correction, display of the authoritative form of the term entered by the user and composition unrecognized input (Metaphrase) (tuttle et al., 1998) Automated Classification (ontylog) Conflict management, detection and resolution (Galapagos) (Campbell et al., 1998) SNOMED Clinical Terms (CT)

 More recently, along with U.K Clinical Terms SNOMED RT has been used as a foundation for a new terminology system, SNOMED CT, which has been developed collaboratively by the college of American Pathologists and the U.K National Health Service ( Wang, Sable & Spackman, 2002) It processes both reference terminology properties and users interface terms. A working group of the SNOMED international Edition Board has led the integration of nursing concepts into SNOMED CT ( Bakken et al., 2002)

Illustrated of Representations Using GALEN and SNOMED RT Approaches Table 18.2 illustrate the representation, using GRAIL and modified KRSS ,of a single nursing activity Although the two representations use different syntax, there are obvious similarities in how the concepts Bladder Irrigation are defined.

Emerging Approaches Outside the health domain, work in relation to the Semantic Web has an resulted in an emerging standard (i.e., a W3C recommendation) ontology language, OWL (W3C, 2004)

OWL
Is intended for use where applications, rather than humans , are to process information As such it should be able to meet the requirements of advanced terminology system that supports contemporary healthcare.

 It builds on existing recommendations such as extensible Make-up Language (XML) (surface syntax for structured placements), Resource Description Framework (RDF) a data model for resources and RDF Schema ( a vocabulary for describing the properties and Classes of resources) by providing additional vocabulary and a formal semantics

Software, both proprietary and Open source is available for : Managing terminology models as ontologies developed in OWL (e.g., Protg [ Noy et al., 2003] with an OWL plug-in) Reasoning on the model (e.g., Racer [ Hearslev & Moller, 2001])

 Although work within nursing (e.g., supporting the development of ICNP Version 1) and the wider health informatics community is still in its infancy, the results to date are promising. an OWL representation ( in XML) of the nursing activity concept Bladder Irrigation is provided in Table 18.3 for comparison with the GRAIL and KRSS representations in Table 18.2

Advanced Terminology Systems in Practice Figure 18.5 displays a potential mapping (to the night of the Figure) between the NIC concept Bladder Irrigation ( Mc Closkey & Bulechek,2000) and the Pre-coordinated Omaha System Concept Treatments and Procedures: Bladder Care ( Martin & Scheet,1992)

 A computer-based reasoned can use the formal definitions of the corresponding composed concepts to infer hierarchical relationships. The asserted properties for both concepts (in the center of the figure) are identical. The existing hierarchy (to the left of the figure) asserts that performing subsumes irrigating

 Thus, Bladder Care, which maps to the Omaha System Concept Treatment and Procedures: Bladder Care, is a generalization of Bladder Irrigation, hence, the NIC concepts Bladder Irrigation potentially maps onto the Omaha System Concepts Treatment and Procedures: Bladder Care ( But not Vice versa)

Implementing and Upgrading Clinical Information

chapter 19

What is clinical information?

Nursing involvement in the design and implementation of CIS is required at many levels. The nursing process used to deliver direct patient care, which provides a strong parallel framework for nurses to succeed in the design and implementation of CIS project. A CIS assist clinicians with data necessary for decision and problem solving. A CIS must serve the organization and the patient in much the same way an efficient health care is.

There are four major CIS requirements: Administer a nursing department Assist the management of nursing practice Assist in nursing education Support nursing research

Clinical Information System Committee Structure and Project Staff

The nursing administrators involvement in the establishment of a CIS committee structure I s paramount to the e success of the project. The nursing administrator, in conjunction with the information systems management team, works to develop a committee structure and participation to best guarantee the success of the project.

Clinical Information System Committee Structure and Project Staff

The nursing administrator must both direct the impact as well as be a visible leader in planning and leading the transition management efforts. A three-tiered committee approach is recommended to accomplish the design, implementation or upgrading of a complete CIS-a steering committee, a project team, and departmental teams.

Clinical Information System Committee

Before a CIS is developed or selected, the organization must appoint a CIS steering committee. It generally includes the following areas: Hospital administrator/ hospital finance Nursing administration Medical staff

Clinical Information System Committee

Information systems department Major ancillary department(laboratory, radiology, pharmacy, dietary, medical records/patient registration, patient accounting) Health information management Legal affairs Outside consultants Other appointed members

Project Team

Project Team
The project team is led by an appointed project manager and includes a designated team leader for each of the MAJOR DEPARTMENTS affected by the team selection, implementation, or upgrade proposed. The objectives of the project team are: Understand the technology and technology restrictions if any of a proposed system

Project Team
Understand the impact of the intradepartmental decisions. Make decisions at the intradepartmental level for the overall good of the CIS within the organization. Become the key resource for their application

.a stated goal for the CIS is to improve patient care; gains made by one department to the expense of the another department rarely work to improve overall patient care delivery.

Departmental teams
The charge of the departmental teams is : to thoroughly understand the departments information needs to gain full understanding of the softwares features and functions to merge the new systems capabilities with the departments operations

 to assist in the system testing effort to participate in developing and conducting end user education, and to provide high level of support during the initial activation period of a new system

Functional design
Is the overview statement of how the new system will work. It uses the workflow documents as its base, adding the critical documents of the integration of each of the workflow documents to create a new system, implement a commercial software application, or upgrade a system. It concise description of the functions required from the proposed computerized system and describes how the application will accomplish its task

The System Design Phase

The design phase details of the system term and the detailed plans for implementing the system are developed for both the functional and the technical components of the system. There are 3 major steps: 1. functional specification 2. Technical specification 3. Implementation planning

Functional system
Used the functional design document developed in the system analysis phase of a CIS(clinical information system) n d builds on the design for formulating a detailed description of ALL system inputs, outputs and processing logic required to complete the scope of the project.

Data Manipulation and Output

This step the departmental teams and the users determined what the actual data will look like in its output form and gain consensus from the departmental teams for the proposed design. The following criteria are considered essential in selecting a CIS and can be use as basis for evaluation 1. Application 2. Use of industry performance connectivity

3. Evaluation features and pathways 4. Ease or system use 5. Configuration or programming performance 6. Security 7. Simplification of reports 8. Database access 9. Hardware and software reliability 10. Connectivity 11. System cost

Technical Specification
Technical personnel work closely with the project and departmental teams to ensure the technical components of the proposed system work in concert with technology and end-user needs and to assist in the development of the implementation plan. The 54major areas include: hardware, software, interfaces, and conversions.

Implementation planning
The last step in the system design is to establish a detailed implementation. This plan coordinates all task necessary to complete the development of new software, implement a ne system, and or upgrade a current system.

 On the other hand, if the project steering committee decides to develop its own system programs, the project staff must proceed with the development phase of the system, which includes the following: 1. Select hardware 2. Development software 3. Test system 4. Document system

The Testing Phase

Testing verifies that the computer programs are written correctly and ensures that when implemented in the production environment, the system will function as planned.

Document system
To described the system for all users is an ongoing activity, with development of the documentation occurring as the various system phases and steps are completed.

Users Manual
It highlights how to use the system and describes what outputs the system can produce. With commercially available software, the vendors users manual helps the organizations training manual.

Operators Maintenance Manual

This manuals enables to keep the system up and running by providing the functional and technical specification detail such that system users and operators understand how the system was developed, how it operates, and how it can be maintained, updated, and repaired.

The Training Phase

Training takes place before and during the activation of a new system. Training is the most effective when hands-on , interactive instruction is provided. Training guides or manuals explained the system; however retention of information is increased if the learners are able to interact with the new system.

The Implementation Phase

This phase ensures that once the system is installed in the live environment, the system and the delivery of healthcare in the organization will run smoothly.

The Evaluation Phase

The evaluation phase described and assesses, in detail, the new systems performance. Using the criteria established in the planning and system design phases, the evaluation process summarizes the entire system.

Data Analysis
The second step in the system analysis phase . The analysis provides the data for development of an overview of the nursing problem and/or stated goal defined in the project scope agreement. 1. Data 2. grid chart 3. decision table 4. Organizational chart

Data Review
Third step in the analysis phase is to review the data collected in the feasibility study, the workflow documents, and the functional specification and provide recommendations to the project steering committee for the new system. Focuses on resolving the problems and/or attaining the goal defined in the feasibility study based on the based methods or pathways derived from the workflow documents and the functional design.

Benefits Identification
The overall anticipated benefits from the system are documented in the fourth step in the system analysis process. The benefits reflect the resolution of the identified problem, formulated and stated in quantifiable terms. The proposed benefits statements becomes the criteria for measuring the success if the project.

System Proposal System

The final step in the system analysis stage. Is to create a system proposal document. The proposal is submitted to the projects steering committee for review and approval. It outlines the standards, documentation, and procedures for management control project, and it defines the information required, the necessary resources, anticipated benefits, a detailed work plan, and projected cots for the new system

Final System Proposal

The format for the final system proposal includes the following information: 1. a concise statement of the problem and or goal 2. Background information related to the problem

Final System Proposal

3. Environmental factors related to the problem a. Competition b. Economics c. Politics d. Ethics 4. anticipated benefits 5. Proposed solutions 6. Budgetary and resources requirements 7. Project timetable