Mapping the Dutch SNOMED CT subset to Omaha System, NANDA International and International Classification of Functioning, Disability and Health.

BACKGROUND: Nurses register data in electronic health records, which can use various terminology and coding systems. The net result is that information cannot be exchanged and reused properly, for example when a patient is transferred from one care setting to another. A nursing subset of patient problems was therefore developed in the Netherlands, based on comparable and exchangeable terms that are used throughout the healthcare sector and elsewhere (semantic interoperability). The purpose of the current research is to develop a mapping between the subset of patient problems and three classifications in order to improve the exchangeability of data. Those classifications are the Omaha System, NANDA International, and ICF (the International Classification of Functioning, Disability and Health). METHOD: Descriptive research using a unidirectional mapping strategy. RESULTS: Some 30%-39% of the 119 SNOMED CT patient problems can be mapped one-to-one from the subset onto each separate classification. Between 6% and 8% have been mapped partially to a related term. This is considered to be a one-to-one mapping, although the meanings do not correspond fully. Additionally, 23%-51% of the patient problems could be mapped n-to-one, i.e. more specifically than the classification. Some loss of information will always occur in such exchanges. Between 1% and 4% of the patient problems from the subset are defined less specifically than the problems within the individual classifications. Finally, it turns out that 9%-32% of the terms from the subset of patient problems could not be mapped onto a classification, either because they did not occur in the classification or because they could not be mapped at a higher level. CONCLUSION: To promote the exchange of data, the subset of patient problems has been mapped onto three classifications. Loss of information occurs in most cases when the patient problems are transformed from the subset into a classification. This arises because the classifications are different in structure and in the degree of detail. Structural cooperation between suppliers, healthcare organisations and the experts involved is required in order to determine how the mapping should be used within the electronic health records, and whether it is usable in day-to-day practice.

The development of a nursing subset of patient problems to support interoperability.

BACKGROUND: Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information. METHODS: Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives. RESULTS: Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier. CONCLUSIONS: To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning.