A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> To see whether the National Library of Medicine's Metathesaurus (tm) includes terminology relevant to clinical nursing practice, two widely used nursing vocabularies were matched against the Meta. The two nursing vocabularies are 1) the North American Nursing Diagnosis List of Approved Diagnoses; and 2) the Omaha System, a vocabulary of problems and interventions developed by the Omaha Visiting Nurses Association. First, the terms were scanned against Meta in their "native" form, with phrases and combinations intact. This produced a relatively low percentage of exact matches (12%). Next, the terms were separated into "core concepts" and "modifiers" and the analysis was repeated. The percentage of exact matches to terms in Meta increased to 32%. However, the semantic types of the split terms often were not equivalent to the semantic types of the phrases from which the split terms were derived; also, in some cases, terms returned as exact matches had different meanings in Meta. Automatic scanning for lexical matches is a helpful first step in searching for vocabulary representation in Meta, but term-by-term search for context, semantic type and definition is essential. However, it seems clear that representation of nursing terminology in the Metathesaurus needs to be expanded. <s> BIB001 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> In 1986, the National Library of Medicine began a long-term research and development project to build the Unified Medical Language System® (UMLS®). The purpose of the UMLS is to improve the ability of computer programs to "understand" the biomedical meaning in user inquiries and to use this understanding to retrieve and integrate relevant machine-readable information for users. Underlying the UMLS effort is the assumption that timely access to accurate and up-to-date information will improve decision making and ultimately the quality of patient care and research. The development of the UMLS is a distributed national experiment with a strong element of international collaboration. The general strategy is to develop UMLS components through a series of successive approximations of the capabilities ultimately desired. Three experimental Knowledge Sources, the Metathesaurus®, the Semantic Network, and the Information Sources Map have been developed and are distributed annually to interested researchers, many of whom have tested and evaluated them in a range of applications. The UMLS project and current developments in high-speed, high-capacity international networks are converging in ways that have great potential for enhancing access to biomedical information. <s> BIB002 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Objective : To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms. ::: ::: Design : Prospective research design with manual matching of terms to the SNOMED III vocabulary. ::: ::: Measurements : The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms. ::: ::: Results : Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms. <s> BIB003 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Everyday clinical nursing language is informal and idiosyncratic. Whether the everyday language of nurses can be represented by standardized vocabulary systems, such as the UMLS and SNOMED, was the focus of the study. Computer systems that allow clinicians to pick terms that are familiar are likely to be better accepted and thus more effective than systems that impose formal terminologies on users. Nursing phrases were extracted from handwritten shift notes, reduced to atomic-level terms, and matched to UMLS and SNOMED. Exact matches were obtained for 56% of terms in UMLS and 49% in SNOMED. Fifty-nine semantic types and 24 different source vocabularies were represented by the terms. Nursing vocabularies were represented by only 5% of source vocabulary citations. <s> BIB004 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Society mandates that health care be both effective and affordable. Currently, data about costs of care are more readily obtainable than data about quality, especially in relation to nursing and other nonphysician aspects of patient care. Assessing effectiveness of care requires standardized data aggregated in databases for comparisons across times, conditions, and institutions. Historical and contemporary efforts to identify elements of a minimum data set and develop standards have brought progress but have not resolved all the critical issues. A project involving the University Hospital Consortium and its member institutions has produced a valid and reliable set of standard terms and codes compatible with an existing patient-level database. Future developments need to include better methods for determining resource consumption and for capturing clinical data. The time is near when databases built from clinical data will lead to knowledge that will strengthen patient care. <s> BIB005 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> PURPOSE ::: To compare the frequency with which nursing activity terms could be categorized using Nursing Interventions Classification (NIC) and Current Procedural Terminology (CPT) codes. ::: ::: ::: DESIGN ::: Descriptive. The sample was 201 patients with AIDS hospitalized 1989-1992 for pneumocystis carinii pneumonia in three US medical centers. ::: ::: ::: METHODS ::: Nursing activity terms (n = 21,366) were collected from patient interviews, nurse interviews, intershift reports, and patient records, then were categorized using NIC and CPT codes. ::: ::: ::: RESULTS ::: Nursing activity terms were categorized into 80 NIC interventions across 22 classes and into 15 CPT codes. All terms in the data set were classifiable using the NIC system and the majority (60%) of the terms were classified into 14 NIC intervention categories; 6% of the terms were classifiable by CPT codes. The most frequently used CPT code was "pulse oximetry." Significantly (p < .0001) greater numbers of nursing activity terms could be categorized in the NIC system compared to the CPT system. ::: ::: ::: CONCLUSIONS ::: Findings provide evidence that NIC is superior to CPT for categorizing nursing activities in this study's population. The findings support the importance of discipline-specific classifications for categorization of health care interventions. Nursing-specific intervention classification systems such as NIC, the Omaha System, and the Home Health Care Classification are essential to defining the contribution of nursing to both quality and cost outcomes. <s> BIB006 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Abstract The GALEN representation and integration language (GRAIL) has been developed to support effective clinical user interfaces and extensible re-usable models of medical terminology. It has been used successfully to develop the prototype GALEN common reference (CORE) model for medical terminology and for a series of projects in clinical user interfaces within the GALEN and PEN&PAD projects. GRAIL is a description logic or frame language with novel features to support part-whole and other transitive relations and to support the GALEN modelling style aimed at re-use and application independence. GRAIL began as an experimental language. However, it has clarified many requirements for an effective knowledge representation language for clinical concepts. It still has numerous limitations despite its practical successes. The GRAIL experience is expected to form the basis for future languages which meet the same requirements but have greater expressiveness and more soundly based semantics. This paper provides a description and motivation for the GRAIL language and gives examples of the modelling paradigm which it supports. <s> BIB007 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> A variety of strategies for knowledge representation have been applied to the texts from a number of medical domains. Many of the techniques rely on the well-defined ways in which medical terms are used within a given domain, a phenomenon referred to as 'sublanguage.' Because much of nursing documentation involves the use of 'everyday' language, the viable application of sublanguage-based approaches to knowledge representation of nursing documentation is not a forgone conclusion. We propose an approach utilizing semantic markup of nursing notes as a strategy for determining whether the documentation of 'what nurses do' is a sublanguage Results of an initial feasibility study utilizing the approach are presented. <s> BIB008 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Objective: The purpose of the study is to explore the use of formal systems to model nursing terminology. ::: ::: Design: GRAIL is a formal, compositional terminologic language, closely related to frame-based systems and conceptual graphs, which allows concepts to be formed from atomic-level primitives and automatically classified in a multiple hierarchy. A formal model of the alpha version of the International Classification for Nursing Practice (ICNP) classification of nursing interventions was constructed in GRAIL. ::: ::: Measurements: The model was analyzed for completeness, coherence, clarity, expressiveness, usefulness, and maintainability. ::: ::: Results: GRAIL is capable of representing the complete set of atomic-level concepts within the ICNP as well as certain cross-mappings to other vocabularies. It also has the potential to represent many more concepts, to an arbitrary level of detail. ::: ::: Conclusions: Formal systems such as GRAIL can overcome many of the difficulties associated with traditional nursing vocabularies without restricting the level of detail needed to describe nursing care. <s> BIB009 </s> A Review of Major Nursing Vocabularies and the Extent to Which They Have the Characteristics Required for Implementation in Computer-based Systems <s> Complete and comprehensive coverage of the clinical spectrum with sufficient granularity (depth and level of detail) <s> Scalable methodologies for distributed development of logic-based convergent medical terminology. - <s> BIB010
to depict the clinical process. As noted earlier in this article, rigorously designed nursing vocabularies exist for diagnoses, interventions, and outcomes. A series of validation studies have demonstrated the utility of the ANA-recognized systems for the abstraction or categorization of nursing data. 26 -29 Additional studies have demonstrated the utility of vocabulary systems not specifically designed for nursing for the representation of nursing data in intershift reports and the terms nurses use to document patient problems in the patient record. BIB003 BIB004 Conversely, a comparative study of the NIC and Current Procedural Terminology 31 codes demonstrated the superiority of the NIC for the categorization of nursing activities and supported Zielstorff's earlier findings on the need for nursing-specific vocabularies. BIB006 BIB001 With regard to depth and level of detail, a number of investigations have provided evidence that the granularity of ANA-recognized vocabulary systems is not sufficient to support multiple data uses within computer-based systems. BIB003    This is not surprising, given their primary purpose of classification. In contrast, the nursing intervention scheme of the alpha version of the ICNP comprises atomic-level terms.  Clear and non-redundant concept representation with concise definitions. The ANA-recognized vocabulary systems have definitions for their components: problems, interventions, and outcomes. 10 -14 The vocabularies also include defining characteristics for NANDA diagnoses, representative activities for NIC interventions, and indicators for NOC outcomes. The ICNP includes definitions for nursing phenomena and nursing interventions.  However, no formal definitions of concepts in terms of a terminology model comprising concepts and relationships represented using a description logic formalism (e.g., conceptual graphs) are included in any of the six systems. In addition, none of the systems includes a mechanism to ensure nonredundant concept representation. Atomic and compositional character with syntax and grammar for the composition of complex concepts. Some nursing vocabularies (e.g., the HHCC and Omaha System) have compositional characteristics, although, with the exception of the ICNP, 1,36 the systems themselves are not conceptualized as multi-axial by their developers. For representation of nursing activities, the ICNP includes the following axes: action types, object types, types of approaches, means, anatomic sites, and time/ place.  Sources of atomic-level terms in addition to selected portions of the ANA-recognized vocabularies and the ICNP that have potential utility for nursing include the Patient Care Data Set, BIB005 SNOMED International,  and proprietary data sets. The work on defining the syntax and grammar for combining nursing concepts into logical and clinically relevant constructions is in its infancy. As shown in Table 6 , Hardiker and Kirby 6 reported the use of the GALEN Representation and Integration Language (GRAIL) BIB007 to extend the GALEN Medical Foundation Model for representation of nursing concepts, and Henry and Mead  proposed a basic terminology model for defining nursing activities using conceptual graphs. A recent test of a converged model for nursing activities demonstrated that that target, recipient, and mode of action were universally present in 100 terms from a home care data set. BIB008 To further illustrate the status of the selected nursing vocabularies related to this criterion, Table 7 compares the attributes of nursing interventions as proposed in three terminology models and lists potential sources of atomic terms to serve as values for the attributes.   BIB009  Notice that the only attributes of the GRAIL representation included in the table are those specifically illustrated by Hardiker and Rector 40 in relationship to the ICNP and thus are not intended to be reflective of the expressiveness of GRAIL in its entirety. Synonyms. None of the vocabularies reviewed explicitly supports synonyms. Attributes. The intervention schemes of the HHCC, Omaha System, and ICNP include mechanisms to modify or qualify a core term. For example, in all three systems a core term for nursing intervention can be modified by the particular mode of delivery or type of action (e.g., teaching, managing, observing). The NANDA Taxonomy and HHCC both differentiate between ''at Risk for'' and actual problems. Uncertainty (graduated record of certainty for findings and assessments). Four of the nursing vocabularies (the NANDA Taxonomy, HHCC, Omaha System, and ICNP) include some type of scheme for findings and assessments including nursing diagnoses. However, none of them includes a graduated certainty scale. Hierarchies and inheritance (multiple parents or children as clinically appropriate). The NANDA Taxonomy, Omaha System, and HHCC have hierarchic structures with multiple children but not multiple parents. In addition to a hierarchic structure with multiple children, the NIC explicitly includes multiple parents (classes) for some interventions and, less explicitly, multiple parents (interventions) for activity terms. The architecture of the alpha version of the ICNP provides for multiple hierarchies in the intervention scheme but not in the nursing phenomenon. Recent reports have described the use of tools including K-Rep 42 and GRAIL BIB007 for terminology management including automatic classification of newly composed concepts into multiple hierarchies. Campbell et al. BIB010 reported the implementation of Gálapagos, a configuration and conflict resolution environment built on top of K-Rep, and Zingo 44 described initial work on defining nursing concepts within the environment. Hardiker et al.  BIB009 discussed the use of GRAIL to model and classify the ICNP concepts within GALEN. Administrative cross-references. In the United States, as selected nursing vocabularies become part of the Unified Medical Language System (UMLS), BIB002 