Validation of concept mapping between PNDS and SNOMED CT

AORN Journal, June, 2008 by Bonnie L. Westra, Rhonda Bauman, Connie W. Delaney, Cynthia B. Lundberg, Carol Petersen

The importance of using standardized nursing terminologies has been emphasized by several key organizations. The American Nurses Association (ANA) has developed criteria based on the International Standards Organization to recognize nursing terminologies that are reliable, valid, and useful for practice. (1) The Joint Commission requires the use of standardized terminologies in electronic health records (EHRs) (2) as does the federal government in its certification process of information systems. (3) The certification process for information systems exists as a result of an executive order of President George W. Bush in 2004 that all Americans will have an interoperable EHR (ie, one that is transferable between all health care settings) by 2014. (4)

Incorporation of one or more standardized terminologies into EHRs allows for consistent documentation of patient care, interoperability, and exchange of data between clinical information systems. It also provides a means to investigate individual patients and population trends to develop best practice guidelines for patient care and supports nursing research for individual health care organizations and comparisons across local, state, national, and international organizations. (5) The word terminology as it is used throughout this article is synonymous with standardized language, vocabulary, classification, or nomenclature.

In 2000, AORN developed the Perioperative Nursing Data Set (PNDS) for use in perioperative clinical documentation. (6) The PNDS was mapped to the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) in July 2003 by SNOMED CT staff members to support the electronic exchange of data. Although the PNDS has been integrated within the SNOMED CT, this mapping had not been formally validated.

PURPOSE OF THE STUDY

The purpose of this study was to validate the mapping of concepts between the PNDS and the SNOMED CT to ensure that concepts represented in one system have equivalent meanings in the other system. The specific aims of the study were to

* validate semantic comparability between the two terminology systems,

* evaluate the placement of PNDS concepts in the SNOMED CT hierarchy, and

* identify whether the assignment of PNDS concepts in the SNOMED CT hierarchy is similar for all mapped PNDS concepts.

Terminology used throughout this article is defined in Table 1 with accompanying examples.

SIGNIFICANCE OF THIS STUDY

The PNDS was developed by AORN to guide the documentation of nursing practice through the use of consistent terminology across varied health care settings. (6) The PNDS was mapped to the SNOMED CT to support the exchange of nursing data electronically with other specialties and across information systems to provide continuity, which may result in better and safer patient care. The use of standardized terminologies such as the PNDS allows for an aggregation of patient data to describe best practices and allows research to be performed using routine clinical documentation. When the PNDS is linked with other terminologies, researchers can track trends in patient populations over time and across health care specialties and settings. This functionality prevents redundant data capture while assisting with billing, statistical analysis, and health reporting. (5,7)

Linking the PNDS with other terminologies also supports the potential for new ways of developing nursing knowledge. For instance, knowledge discovery in databases, (eg, data mining) is a cutting-edge research method that uses semi-automated, artificial intelligence to explore large databases (eg, EHRs) to reveal relationships in data. This ability to explore EHRs may help researchers better understand the complexity of factors that influence patient outcomes. It is important, therefore, to ensure that concepts mapped between terminologies have comparable meaning both for practice and knowledge development.

LITERATURE REVIEW

The lack of consistency in describing patient needs and care has been criticized since the nursing profession began. In fact, there are some who believe that inconsistent use of standardized vocabularies has stifled the advancement of the nursing profession. (8) Lack of a standardized language leads to numerous interpretations of data and increases the potential for error.

Terminologies provide the content or words to document care within the structure of the nursing process. The nursing process determines which concepts are important to nursing for standardization. Diagnoses or problems are key concepts that ultimately guide the selection of nursing interventions and outcomes? Studies have demonstrated the ability of standardized languages to support documentation and evaluation of the nursing process. (10-13)

No single terminology, classification, language, or nomenclature system has been developed that adequately encapsulates the breadth and depth of nursing care across all specialties and settings. In fact, 12 standardized languages or terminologies for nursing have been recognized by the ANA. (1) To achieve this recognition, these terminology systems must be maintained and the terminology must be updated on an ongoing basis to reflect the changing nature of nursing practice. Nurse practice committees and administrators determine the most appropriate terminology for their specialty practice; however, this means that as patients transition from one clinical specialty or setting to another, many different standardized terminologies may be used to electronically communicate patient needs and care through the health care continuum.