International Journal of Medical Informatics 134 (2020) 104035

Contents lists available at ScienceDirect

International Journal of Medical Informatics

journal homepage: www.elsevier.com/locate/ijmedinf

Review article

Towards implementing SNOMED CT in nursing practice: A scoping review T

a b c c
Junglyun Kim , Tamara G.R. Macieira , Sarah L. Meyer , Margaret Ansell (Maggie) ,
Ragnhildur I. Bjarnadottir (Raga)b, Madison B. Smithd, Sandra Wolfe Cittyb,
Denise M. Schentrupb, Rose Marie Nealisb, Gail M. Keenanb,*
a
Adult and Gerontological Health Cooperative Unit, School of Nursing, University of Minnesota, 308 Harvard Street SE, Minneapolis, MN 55455, United States
b
Department of Family, Community and Health System Science, College of Nursing, University of Florida, PO Box 100197, Gainesville, FL 32610, United States
c
Health Science Center Libraries, University of Florida, Communicore Building, SW Archer Rd, Gainesville, FL 32610, United States
d
College of Nursing, University of Florida, PO Box 100197, Gainesville, FL 32610, United States

ARTICLE INFO ABSTRACT

Keywords: Background: Currently, it is rare for nursing data to be available in data repositories due to the quality of nursing
Mapping data collected in clinical practice. To improve the quality of nursing data, the American Nurses Association
Nursing terminologies recommends the use of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for coding nursing
SNOMED CT problems, interventions, and observations in electronic health records.
System Development Life Cycle
Objective: To determine “what is known about the use of SNOMED terminology (Pre-SNOMED CT and SNOMED
Interoperability
CT) in nursing”.
Methods: We searched four databases and two search engines. We identified 29 articles for review. A modified
version of System Development Life Cycle (SDLC), and Mapping Evaluation Assessment (MEA), created by the
authors were used for quality assessment.
Results: All 29 studies mapped standardized (n = 19) or local nursing terms (n = 10) to the SNOMED termi-
nology. MEA scores ranged from 2-8 (range 0-11) with 25 receiving scores from 5-8. On the modified SDLC
(range 0–5), all studies exhibited activities of stage 0 (pre-application integration), with two studies describing
integration and preliminary testing of SNOMED CT coded nursing content in applications (stage 2).
Conclusion: Though efforts are underway to ensure adequate coverage of nursing in SNOMED CT, there were no
studies indicating use in nursing practice. The authors offer recommendations for achieving the widespread
collection of interoperable SNOMED CT coded nursing data in clinical applications to evaluate nursing’s impact
on patient outcomes. These include creating a clear professional vision and path to our data goals that builds on
sound rationale and evidence, abundant stakeholder engagement, and sufficient resources.

1. Introduction represent data with controlled or standardized vocabularies, also called

terminologies. Using standardized vocabularies to represent nursing
At the heart of advancing nursing practice is the deep commitment care in EHRs can result in the generation of data to identify best nursing
by the profession to deliver care based on the best research evidence evidence and enable clinical decision support systems. Experts often
and clinical expertise individualized to the patient’s values, wishes, and refer to two types of terminologies: a) interface and b) reference. An
health profile [1]. The development and rapid implementation of interface terminology is that which the clinician sees at the point-of-
electronic health records (EHRs) have resulted in an unprecedented care and comprises actual terms used to document the care provided to
volume of electronic patient data available in clinical data repositories patients [5]. Interface terminologies are often specific to particular
for the potential use in identifying evidence for continuous improve- disciplines, such as nursing, medicine, or physical therapy. The stan-
ment of health care practices [2]. The insights gleaned, however, are dardized nursing terminologies (SNT) are examples of interface ter-
dependent on the data gathered and the quality of data [3]. Currently, it minologies (e.g., NANDA International [NANDA-I], Nursing Outcomes
is rare for nursing data to be available in data repositories due to the Classification [NOC], Nursing Interventions Classification [NIC], Clin-
quality of nursing data collected in clinical practice [4]. ical Care Classification [CCC], Omaha System, International Classifi-
One mechanism for improving the quality of nursing data is to cation for Nursing Practice [ICNP], Perioperative Nursing Data Set

⁎
Corresponding author at: PO Box 100187, Gainesville, FL 32610-0187, United States.
E-mail address: [email protected] (G.M. Keenan).

https://doi.org/10.1016/j.ijmedinf.2019.104035
Received 14 August 2019; Received in revised form 20 October 2019; Accepted 22 November 2019
1386-5056/ © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

[PNDS]) [5,6]. Reference terminologies typically serve as the behind- search strategies developed used a combination of keywords and con-
the-scenes glue that makes it possible for different interface terminol- trolled vocabulary related to the core concepts of SNOMED terminology
ogies to talk to each other [5]. The Systematized Nomenclature of and nursing. See Appendix A for detailed search strategies. The search
Medicine Clinical Terms (SNOMED CT) and Logical Observation Iden- strategies were developed by two librarians (MA, SM) with expertise in
tifiers Names and Codes (LOINC) are examples of both reference ter- consumer health, nursing, and EHRs, in collaboration with the re-
minologies and interface terminologies [5,6]. SNOMED CT and LOINC maining researchers involved in this review. The librarians (MA, SM)
act as reference terminologies by enabling the comparison of clinician conducted the database searches on April 20, 2018, and uploaded the
data documented with different interface terminologies across settings search results into a reference management program (EndNote Web),
because the interface terms are mapped to the reference terminologies and deleted the duplicates using an automated feature.
[7]. Ideally, interface and reference terminologies work together to
make the data representing nursing care interoperable across health 2.2. Study selection
care systems.
The final rule of the Health Information Technology (Health IT) Two pairs of reviewers participated in the abstract screening and
Certification Criteria, 2015 edition, proposed the SNOMED CT and full-text review for the study selection phase. First, two doctoral stu-
LOINC coding systems as terminology standards for exchanging health dents (TM, MS) independently screened half of the abstracts captured in
information across systems [8]. The SNOMED CT is recognized as a our search strategy, while two researchers with doctoral degrees (RB,
comprehensive healthcare terminology [9] and to date, six of the re- JK) independently screened the remaining half. Abstracts that referred
cognized nursing terminologies have been mapped to it [10]. SNOMED to both SNOMED terminology and nursing were included for further
CT currently contains 340,593 active clinical terms [11] and is main- review. Pair members resolved discrepancies through discussion and
tained by the International Health Terminology Standards Development when this was not possible, articles were included for further review.
Organization (IHTSDO) [12]. LOINC codes include laboratory and other Next, the two pairs of reviewers performed full-text review. In this re-
clinical observations and it is maintained by the Regenstrief Institute, view, each member of a pair independently scanned a set of full-text
Inc [13]. articles to validate that each article met the inclusion criteria. Once
In the 2015 [14] and 2018 [15] position statements, the American again, the discrepancies were resolved by discussion or by a group of
Nurses Association (ANA) reaffirmed its support for the use of ANA- researchers (GK, DS, RN, SC) as needed.
recognized terminologies to represent nursing practice in EHRs. The To be included an article was required to have a significant em-
statement specifically recommends the use of SNOMED CT (for coding phasis on SNOMED terminology use in a nursing context. Criteria for
problems, interventions, and observations) and LOINC (for coding as- exclusion were: 1) articles not published in English; 2) articles that did
sessments and outcomes) [15] when exchanging a Consolidated Con- not express direct implication of the research/findings to nursing
tinuity of Care Document (HL7 Consolidated Clinical Document Ar- practice; 3) articles written for education purposes; 4) announcements;
chitecture [C-CDA]) for problems and care plans between settings. The 5) bulletins; 6) opinions; and 7) articles that did not present a direct
ANA’s positions thus align with the Office of the National Coordinator connection between SNOMED terminology and nursing. We defined
for Health Information Technology (ONC Health IT) Certification pro- “direct implication of the research/findings to nursing practice” as
gram [7] and the Medicare and Medicaid EHR Incentive Program that description by the authors on how a) the SNOMED terminology content
support health IT adoption, interoperability, and quality improvement (e.g. mapping, description) covered in the study would inform/en-
[16]. hance/influence nursing practice, and/or how b) the study’s findings
The inclusion of terminologies that represent nursing practice in can be actually used in nursing practice. For example, one study
EHRs is vital to generating interoperable data. The availability of in- mapped both nursing and physicians’ free-text data to SNOMED CT but
teroperable data in EHRs provides the foundation for enhancing care was excluded because there were no specific results or discussion re-
continuity, developing sound clinical decision support, tracking patient lated to the nursing content of the dataset [21]. Another study that
outcomes, and conducting disciplinary and interdisciplinary research mapped preexisting nursing perianesthesia concepts to SNOMED CT
[17,18]. Although the ANA strongly advocates for the use of SNOMED was excluded because the rationale for the nursing mappings was not
CT and LOINC, this paper focuses on understanding what is known discussed [22]. Fig. 1 is an illustration of the selection process.
about the use of SNOMED terminology in nursing. This is because
SNOMED terminology includes concepts that represent elements of 2.3. Data extraction
interest to nursing.
We extracted the following key data elements from each of the
2. Materials and methods studies where available: authors, publication year, purpose, research
questions, variables, study design, sample size and characteristics, data
The project team performed a review of studies that used the source, summary of methods, results, and authors descriptions of the
SNOMED terminology (Pre-SNOMED CT and SNOMED CT versions) in a significance of the SNOMED terminology relevant results to nursing
nursing context. Pre-SNOMED CT refers to any version (e.g., SNOMED practice. Data extraction involved three consecutive rounds. In round
III) of the SNOMED terminology existing prior to the release of the first one, each of seven reviewers (GK, JK, TM, RB, SC, RN, DS) was assigned
SNOMED CT in 1999. The team followed the protocol registered in the individually to extract the key data elements from 3 to 9 of the 29
International Prospective Register of Systematic Reviews (PROSPERO) studies. In round two, all studies were then divided up among three
[19] which was developed according to the Preferred Reporting Items reviewers (GK, JK, TM) who examined the data extracted in round one
for Systematic Reviews and Meta-Analyses (PRISMA) Statement [20]. for clarity and completeness and further searched the articles to locate
any missing items. In round three, one expert reviewer (GK) conducted
2.1. Data sources and search strategy a final review to ensure table items were clear and accurate.

The question that this scoping review sought to answer is “what is 2.4. Quality assessment
known about the use of SNOMED terminology in nursing?” Searched
databases included PubMed, CINAHL, Web of Science, and Cochrane Each study was evaluated with two types of assessment; a modified
Library’s Health Technology Assessment (HTA) database, with no lan- version of the System Development Life Cycle (SDLC) [23] and a
guage or date restrictions. The grey literature was searched using Mapping Evaluation Assessment (MEA) created by the authors. The
Google and Google Scholar. To capture all relevant literature, the modified six-stage (0–5) SDLC model was used to assess the stage of

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J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

Fig. 1. PRISMA flow diagram: study selection process.

Table 1
Modified SDLC.a
Development Stage Evaluation Focus Evaluation Goal

Stage 0 – Mapping nursing terms to SNOMED; identifying and 0-task To determine extent of SNOMED coverage for nursing care domain/s:
addressing deficits and errors. 1-task-user Mapping performed to determine extent to which SNOMED covers the specified
content.
Content is validated in use case.
Stage 1 – Create electronic application/system specifications 0-task Develop specifications for integrating SNOMED content:
for target use. 1-task-user Describe task to be performed by the system.
Describe how user will interact with the content.
Stage 2 – Electronic application/system component 2-system-task Develop and iteratively test single component/target system in lab:
development and testing (lab). 3-system-task-user Computer engineers test coding for target performance.
Limited set of users test for sensitivity, specificity, speed, accuracy.
Stage 3 – Merge target electronic application/system with 2-system-task Combine target system with other components and iteratively test in lab:
other components and testing (lab). 3-system-task-user Engineers demonstrate system works as intended.
Limited set of users validate system works as intended – efficiency, speed,
learnability, user satisfaction, accuracy, completeness.
Stage 4 – Integrate full system (target electronic application/ 4-system-task-user- Validate that target system integrated with other components works as intended
system & other components) into (real-time) setting. environment under real-time conditions:
Demonstrate quality of performance of the target electronic application/system in the
field – system effectiveness: accuracy, completeness, utilization, workflow efficiency,
user satisfaction.
Stage 5 – Routine use. 4-system-task-user- Assess field impact of target electronic application/system:
environment Demonstrate that data collected with the target system (implemented across sites) is
interoperable and usable for primary and secondary purposes (e.g., evaluate
prescribing behavior, cost benefit, quality of care, guideline adherence, patient
outcomes, medications errors, communication/collaboration, provider patient
relationship, etc.).

Abbreviations: SDLC, system development life cycle; lab, laboratory.

a
The modified six-stage (0–5) SDLC model was used to assess the stage of usage of SNOMED and to determine the evaluation type in each study.

usage of SNOMED terminology and to determine the evaluation focus. the content to be included in an electronic clinical practice application
Evaluation focus indicates which of the four usability components to generate interoperable data. Stage 5 indicates the fully tested in-
(user, tool, task, and environment) or interactions among them should tegration of SNOMED terminology in real time electronic systems.
be evaluated in each development stage [23]. We added stage 0 to the Table 1 includes details of the modified SDLC stages (0–5), evaluation
five-stage (1–5) of SDLC [23] to elucidate the pre-work required to focus and goals. Classifying the SDLC stage of each study contextualizes
ensure the SNOMED terminology has the concepts needed to represent the work accomplished in the study within a framework that links stage

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J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

Fig. 2. Rubric for scoring the Mapping Evaluation Assessment (MEA) created by the authors (range 0–11).

of the progress represented in the study to subsequent steps required to including authors, publication year, SDLC stage and evaluation focus,
achieve the routine collection of valid and reliable interoperable nur- terms mapped in addition to SNOMED terminology, scope and tools,
sing data coded with SNOMED terminology in electronic systems. The nursing elements, mapping validation, next steps, and quality score.
MEA measured the quality of each study’s mapping of nursing terms to Table 3 presents the first author of each article and all other publica-
SNOMED terminology based on four factors; scope, elements mapped, tions within our sample in which they collaborated. Readers can also
validation of mapping, reported next steps. The directions for rating the access additional information about each article in Appendix B.
four major components in mapping studies using the MEA tool are
described in Fig. 2. The scoring range of the four components combined 3.1. Mapping to SNOMED terminology
is between 0–11 points.
Validation of the developmental stage was performed by two of the For all 29 studies, mapping of local terms (n = 10) or standardized
researchers (GK, JK) who independently assigned a SDLC stage (0–5) to terminology (n = 19) to SNOMED terminology (Pre-SNOMED CT
each of the studies. The researchers agreed on 93 % of the cases and [n = 3]; SNOMED CT [n = 26]) was a major component. The mappings
resolved discrepancies through discussion. To validate the mapping to SNOMED terminology were either direct or through the Unified
scores, three researchers (GK, JK, TM) independently scored the four Medical Language System (UMLS), a set of electronic files containing
quality factors for each study. Overall the three researchers agreed on 150 clinical source terminologies in which each term in the source
80 % of the scores and resolved the remaining discrepancies through terminology is mapped to all synonymous terms in the other source
discussion. terminologies [52]. The ANA recognized nursing terminologies, as well
as SNOMED CT are, in full or part, cross-mapped within the UMLS [52].
3. Results The mappings in the studies most frequently involved establishing a
new or validating previous mappings to SNOMED terminology. Seven
Our author team examined 29 research studies. Four of the articles [40,41,43,46,47,50,51] examined cross-mappings of ANA recognized
were from countries outside the United States (Spain, Denmark, terminologies and SNOMED CT with one [47] examining the feasibility
Netherlands, South Korea). Three articles were published during the of automating cross mapping. Four focused on creating nursing problem
1990s, eight were published during 2000s and 18 were published from lists for the United States [40], Denmark [45] and Netherlands [50,51]
2010 until now. Table 2 includes key information items for each study for potential use in electronic systems to produce interoperable nursing

4
 Table 2
Key information about each study.
J. Kim, et al.

Authors Purpose SDLC SDLC Eval Terms Mappeda Scope/ Nursing Mapping Next Steps MEA
Stage Focus Tools Elements Validation Score

Henry, Campbell, Test ability of SNOMED III to represent nurses’ terms 0 0 Care plan, progress note of 485 1 area/ Assmt, NR Solution 4
Holzemer, 1993 [24] describing patient problems for hospitalized AIDS patients encounters, NANDA Manual & querying of a Dx proposed
patients with pneumonia relational database
Henry et al., 1994 [25] Examine feasibility of using SNOMED III to represent 0 0 Interviews, reports, care plans, 1 area/ Assmt, NR Solution 4
nursing terms relevant to hospitalized AIDS patients progress notes of 201 patients from 3 Manual & querying of a Dx proposed
with pneumonia orgs relational database
Lange, 1996 [26] To determine whether the nurses’ text can be 0 0 Shift notes of 14 nurses from 4 med/ > 1area < all/ Assmt, R/no score NR 7
represented by UMLS and SNOMED surg units, UMLS Manual & search algorithm Dx, Intvn,
Outc
Hardiker et al., 2006 [10] To map NANDA to ICNP, for comparing those 0 0 172 Dx from NANDA, ICNP v1.0 All areas/ Dx R/no score Solution 6
representation and relationships within SNOMED CT Not described proposed
Kim H, Harris, Savova, Evaluate concept coverage of SNOMED CT for ICU 0 0 ICU nursing flowsheet and acuity 1 area/ Assmt R/+ score Solution 5
2006 [27] nursing flow sheet and acuity indicators indicators (WinPFS indicators) Clue, App Program Interface proposed
Lu et al., 2006 [28] Develop and test method for detecting editorially 0 0 76 concepts from NIC classes A, B, & > 1 area < all/ Intvn, Outc R/no score Solution 7
misassigned concepts from NIC and NOC to SNOMED CT G and NOC classes A, F, & G Clue Browser executed
Lu et al., 2007 [29] Validate existing mapping between NOC and SNOMED 0 0 NOC All areas/ Outc R/no score Solution 7
CT Manual executed
Lee, Bakken, 2007 [30] Develop prototype for managing obesity to increase 2 2 APN students’ clinical logs from 1 1 area/ Assmt, R/+ score Solution 8
clinical practice guideline adherence Univ, ICD-9, CPG, CCC, UMLS UMLS Knowledge Source Dx, Intvn, proposed
Outc
Park HT et al., 2007 [31] Validate existing mapping between NIC and SNOMED 0 0 514 Intvn from NIC All areas/ Intvn R/no score Solution 7
CT Manual & Clue5 executed
Westra et al., 2008 [32] Validate existing mapping between PNDS and SNOMED 0 0 7 Dx, 133 Intvn, 20 Outc from PNDS 1 area Dx, Intvn, R/no score Solution 6
CT Manual & Clue Outc proposed

5
Park HA et al., 2009 [33] Examine ICNP concepts for their addition and benefits to 0 0 194 Dx, 139 Intvn from ICN All areas/ Dx, Intvn R/no score Solution 7
SNOMED CT and IHTSDO Apelon’s TermWorks, proposed
Clue
Park HA et al., 2010 [34] Map ICNP to SNOMED CT (conference proceedings 0 0 1658 concepts from ICNP v.1 All areas/ Dx, Intvn, R/no score Solution 8
related 2011 article [35]) Apelon’s Termworks, Clue Outc proposed
Park HA et al., 2011 [35] Map ICNP to SNOMED CT 0 0 1658 concepts from ICNP v.1 All areas/ Dx, Intvn, R/no score Solution 8
Apelon’s Termworks, Clue Outc proposed
Wagholikar et al., 2011 Categorize free-text observations into symptom groups 0 0 794 free-text patient complaints/ > 1 area < all/ Assmt, R/+ score Solution 7
[36] (chest or abdominal pain, dyspnea, trauma) by mapping observ at 6 hospital ERs Snapper tool Dx proposed
to SNOMED CT
Harman et al., 2012 [37] To develop interoperable nursing assessment measure 0 0 Flowsheets/57 inpatient DoD > 1 area < all/ Assmt NR Solution 5
facilities, LOINC, HDD 3 M modified mapping tools executed
Warren et al., 2012 [38] Create an ontology model to assist researchers to find 0 1 250 million nursing flowsheet > 1 area < all/ Assmt R/no score Solution 5
nursing data in a repository i2b2 observ, 18 templates derived by 2 Not described proposed
focus groups
Cruanes et al., 2012 [39] Contrast 15 lexical similarity algorithms for mapping a 0 0 4 versions of NANDA-I > 1 area < all/ Dx R/+ score Solution 6
NANDA-I subset to SNOMED CT descriptions in Spanish 15 lexical mapping proposed
algorithms
Matney et al., 2012 [40] Develop interoperable SNOMED CT nursing problem list 0 0 UMLS, HHC, ICNP, NANDA-I, Omaha All areas/ Dx R/no score Solution 7
UMLS browser executed
Kim TY, Coenen, Hardiker, Evaluate representation of mapped concepts between 0 0 UMLS, CCC All areas/ Dx NR Solution 5
2012 [41] CCC, ICNP, NANDA-I and SNOMED CT in UMLS NANDA-I, ICNP Clue & CliniClue proposed
Kim HY & Park HA, 2012 Develop and evaluate CDS to support nurse management 2 3 National guideline information on 1 area/ Assmt NR NR 2
[42] of pressure ulcer wounds pressure ulcer Not described
Kim TY, Hardiker, Coenen Determine the degree overlap between ICNP and 0 0 ICNP, UMLS > 1area < all/ Dx R/+ score Solution 7
2014 [43] SNOMED CT focusing on nursing problems Manual, CliniClue, ICNP executed
browser
Harris et al., 2015 [44] Develop common information models for skin and 0 0 Local terms for skin and wound 1 area/ Assmt, NR Solution 5
wound assessment assmts from 6 orgs, LOINC Not described Dx executed
Hojen et al., 2015 [45] Describe development of Danish national homecare 0 0 1 area/ Dx NR Solution 3
International Journal of Medical Informatics 134 (2020) 104035

nursing subset building on SNOMED CT subset Not described proposed

(continued on next page)
J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

Observation Identifiers Names and Codes, LOINC; International Classification of Functioning, Disability and Health, ICF; International Classification of Diseases, 9th version, ICD-9; Unified Medical Language System, UMLS.
Abbreviations: assessment, Assmt.; diagnosis, Dx.; outcomes, Outc., interventions, Intvn.; not reported, NR; reported with no score, R/no score; reported with score, R/+ score; organizations. orgs; medical/surgical, med/
surg; university, Univ; observations, observ; Department of Defense, DoD; clinical decision support, CDS; electronic health records, EHRs; advanced practice nursing, APN; clinical practice guidelines, CPG; American Nurses
Association, ANA; Informatics for Integrating Biology and the Bedside, i2b2; healthcare data dictionary, HDD; SNOMED Clinical Terms (SNOMED CT); Home Health Classification, HHC; International Classification for
Nursing Practice, ICNP; NANDA-International, NANDA-I; Perioperative Nursing Data Set, PNDS; Nursing Interventions Classification, NIC; Clinical Care Classification, CCC; Nursing Outcomes Classification, NOC; Logical
data.
Score
MEA
In 25 studies, experts and researchers performed the mapping. In

6
four studies [30,38,42,50] both experts and users performed the map-
ping. In 20 studies, authors reported using a combination of both
Next Steps

manual and automated techniques to support mappings between local

proposed

proposed

proposed

proposed
executed

executed
Solution

Solution

Solution

Solution

Solution

Solution
or standardized terms to SNOMED terminology. Automated tools used
to map terms directly or through a secondary source (e.g., UMLS) in-
cluded Clue/CliniClue, 3 M modified tools, SNOMED CT browsers, US
SNOMED CT Content Request Service (USCRS), Snapper, Apelon’s
R/no score

R/no score

R/no score

R/no score
R/+ score
Validation

Termworks, among others. Five studies [10,38,42,44,45] did not report

Mapping

mapping tools. Three studies used manual methods only [29,50,51].

NR
Eight studies did not report the mapping validation process; 15 studies
reported the validation process but did not report reliability scores;
only six studies described the mapping validation process and reliability
Elements

Dx, Outc

scores (See Table 2). Among 29 mapping studies, only two studies
Nursing

Assmt,

Assmt
Intvn

[38,50] included use cases.

Dx

Dx

Dx

3.2. Nursing data elements included

Manual & NORM program

Manual & SNOMED CT

The nursing care data elements examined in the studies included

RELMA, NLM USCRS

one or more of the following: a) assessments, b) diagnoses, c) inter-

> 1area < all/

> 1area < all/

ventions, and d) outcomes. Fifteen studies focused on one of the four

Excel query

elements and 14 focused on two or more. Diagnosis was the most ad-
All areas/

All areas/

All areas/
browsers

Manual

Manual
1 area/

dressed data element (n = 20) and outcome was the least addressed
Scope/
Tools

(n = 7). See Table 2.

Nationwide survey with Dutch nurses
NLM SNOMED CT Nursing Problem

3.3. Scope of nursing practice represented in the mappings

Omaha System, NANDA-I English
100 top med/surg assmts from 6
668 Dx and Outc from ICNP

There were three possible categories for the scope of nursing prac-
16 Dx from Omaha System

tice represented in the study mappings to SNOMED terminology: a) one

area, b) more than one area but not all (> 1 area < all); and c) all
Danish homecare IC
P-FTR, CCC, LOINC

areas (e.g., one area = medical or end of life care; > 1 area <
Terms Mappeda

and Dutch, ICF

with ICF, ICNP

all = medical and surgical units, patients on 20 different units; all

orgs, LOINC

areas = entire scope for a given element or elements, such as nursing

diagnoses (or interventions or outcomes) for all patients regardless of
ICNP
List,

care type or setting). See Fig. 2. Nine studies focused on one type of
nursing care, such as perioperative care [32] and nursing care provided
SDLC Eval

to hospitalized patients with HIV being treated for pneumonia [24,25].

Focus

There were an additional nine studies that focused on more than one
0

area but not all areas. Examples of these include mapping 16 Omaha
Stage
SDLC

System problems that can represent distinct areas of concern and need
0

for different nursing interventions [48] and mapping physiological as-

sessment data from medical and surgical hospital units [49]. For 11
Map minimum set physiological nursing assessments to
Determine which Perinatal Failure to Rescue (P-FTR)

Map Dutch nursing patient problem list to NANDA-I,

studies, the authors focused on representing the whole of nursing

Examine feasibility of automating cross-mapping to

Develop Dutch SNOMED CT subset nursing patient

practice such as validating the mapping between all outcomes terms of

tool data elements are in ANA recognized SNTs

NOC and SNOMED CT [29] and mapping of all diagnoses and inter-
ventions concepts within a version of ICNP to SNOMED CT [33].
Map Omaha System to SNOMED CT

3.4. Study authors’ recommendations for next steps retrieved from the
studies
SNOMED CT with UMLS

SNOMED CT and LOINC

Among 29 studies, 27 suggested next steps or solutions for identified

ICF, Omaha System

issues. Nine studies included evidence that plan/s to carry re-

Terms mapped in addition to SNOMED.

commendations were executed or underway

problem list

[28,29,31,37,40,43,44,49,50]. Examples of executed solutions included

Purpose

passing on recommendations to IHTSDO and terminology developers to

refine existing content or add new SNOMED CT terms [28,33]. Eighteen
of the studies provided recommendations for next steps without evi-
dence of follow up. Examples include suggesting further research to
Monsen et al., 2016 [48]

Matney et al., 2017 [49]

assess the feasibility of using SNTs [24] and enhancing concept models
Kieft et al., 2017 [50]

Kieft et al., 2018 [51]

Table 2 (continued)

to better capture clinical statements [27].

Kim TY, 2016 [47]
Ivory, 2016 [46]

3.5. Quality assessment

Authors

The authors assessed the quality of each study with two measures:
a

1) a modified SDLC and 2) the author developed Mapping Evaluation

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J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

Table 3
First author involvement with one or more studies.a
Year Authorship Study Title

Suzanne Bakken/Henry
1993 S. Bakken Henry, K.E. Campbell, W.L. Holzemer [24] Representation of nursing terms for the description of patient problems using SNOMED
III
1994 S. Bakken Henry, W.K. Holzemer, C.R. Reilly, K.E. Campbell [25] Terms used by nurses to describe patient problems: Can SNOMED III represent nursing
concepts in the patient record?
2007 Nam-Ju Lee, S. Bakken [30] Development of a prototype personal digital assistant-decision support system for the
management of adult obesity
Jorge Cruanes
2012 J. Cruanes, M.T. Romá-Ferri, E. Lloret [39] Measuring lexical similarity methods for textual mapping in nursing diagnosis in Spanish
and SNOMED-CT
Tiffany L. Harman
2012 T.L. Harman, R.A. Seely, I.M. Oliveira, A. Sheide, T. Kartchner, R. D. Standardized mapping of nursing assessments across 59 U.S. military treatment facilities
Woolstenhulme, P.Wilson, L.M. Lau, S. A, Matney [37]
Nicholas R. Hardiker
2006 N.R. Hardiker, A. Casey, A, Coenen, D. Konicek [10] Mutual enhancement of diverse terminologies
2012 T. Y. Kim, A. Coenen, N. Hardiker [41] Semantic mappings and locality of nursing diagnostic concepts in UMLS
2014 T.Y. Kim, N. Hardiker, A. Coenen [43] Inter-terminology mapping of nursing problems
Marcelline R. Harris
2006 H. Kim, M.R. Harris, G. Savova, C.G. Chute [27] Content coverage of SNOMED-CT toward the ICU nursing flowsheets and the acuity
indicators
2015 M. R. Harris, L.H, Langford, H. Miller, M. Hook, P. Dykes, S.A, Matney [44] Harmonizing and extending standards from a domain-specific and bottom-up approach:
an example from development through use in clinical applications
Anne Randorff Højen
2015 A.R. Højen, K. R. Gøeg, P.B. Elberg [45] Re-use of SNOMED CT subset in development of the Danish national standard for home
care nursing problems
Catherine H. Ivory
2016 C.H. Ivory [46] Mapping perinatal nursing process measurement concepts to standard terminologies
R.A.M.M Kieft
2017 R.A.M.M Kieft, E.M. Vreeke, E.M. de Groot, P.A. Volkert, A.L. Francke, D.M.J. The development of a nursing subset of patient problems to support interoperability
Delnoij [50]
2018 R.A.M.M. Kieft, E.M. Vreeke, E.M. de Groot, H.I. de Graaf-Waar, C.H. van Gool, Mapping the Dutch SNOMED CT subset to Omaha system, NANDA international, and
N. Koster, H. ten Napel, A.L. Francke, D.M.J. Delnoij [51] international classification of functioning, disability and health
Hyeoneui Kim
2006 H. Kim, M.R. Harris, G. Savova, C.G. Chute [27] Content coverage of SNOMED-CT toward the ICU nursing flowsheets and the acuity
indicators
Hyun-Young Kim
2012 Hyun-Young Kim, Hyeoun-Ae Park [42] Development and evaluation of data entry templates based on the entity-attribute-value
model for clinical decision support of pressure ulcer wound management
Tae Youn Kim
2012 T. Y. Kim, A. Coenen, N. Hardiker [41] Semantic mappings and locality of nursing diagnostic concepts in UMLS
2012 S.A. Matney, J. J. Warren, J. L. Evans, T.Y.Kim, A.Coenen, V.A. Auld [40] Development of the nursing problem list subset of SNOMED CT
2014 T.Y. Kim, N. Hardiker, A. Coenen [43] Inter-terminology mapping of nursing problems
2016 T. Y. Kim [47] Automating lexical cross-mapping of ICNP to SNOMED CT
Linda L. Lange
1996 L.L. Lange [26] Representation of everyday clinical nursing language in UMLS and SNOMED
Nam-Ju Lee
2007 Nam-Ju Lee, S. Bakken [30] Development of a prototype personal digital assistant-decision support system for the
management of adult obesity
Der-Fa F. Lu
2006 Der-Fa F. Lu, D. Eichmann, D. Konicek, H.T. Park, P. Ucharattana, C. Delaney Standardized nursing language in the systematized nomenclature of medicine clinical
[28] terms: a cross-mapping validation method
2007 Der-Fa Lu, Hyun-Tae Park, P. Ucharattana, D. Konicek, C. Delaney [29] Nursing outcomes classification in the systematized nomenclature of medicine clinical
terms: a cross-mapping validation
2007 Hyun-Tae Park, Der-Fa Lu, D. Konicek, C. Delaney [31] Nursing interventions classification in systematized nomenclature of medicine clinical
terms: a cross-mapping validation
Susan A. Matney
2012 S.A. Matney, J. J. Warren, J. L. Evans, T.Y.Kim, A.Coenen, V.A. Auld [40] Development of the nursing problem list subset of SNOMED CT
2012 T.L. Harman, R.A. Seely, I.M. Oliveira, A. Sheide, T. Kartchner, R. D. Standardized mapping of nursing assessments across 59 U.S. military treatment facilities
Woolstenhulme, P.Wilson, L.M. Lau, S. A, Matney [37]
2015 M. R. Harris, L.H, Langford, H. Miller, M. Hook, P. Dykes, S.A, Matney [44] Harmonizing and extending standards from a domain-specific and bottom-up approach:
an example from development through use in clinical applications
2017 S. A. Matney, T.Settergren, J. Carrington, R. Richesson, A. Scheide, B.L. Westra Standardizing physiologic assessment data to enable big data analytics
[49]
Karen A. Monsen
2016 K.A. Monsen, R.S. Finn, T.E. Fleming, E.J. Garner, A.J. LaValla, J.G. Riemer Rigor in electronic health record knowledge representation: lessons learned from a
[48] SNOMED CT clinical content encoding exercise
Hyeoun-Ae Park
2009 Hyeoun-Ae Park, C.B. Lundberg, A. Coenen, D.J. Konicek [33] Evaluation of the content coverage of SNOMED-CT to represent ICNP version 1
catalogues
2010 Hyeoun-Ae Park, C. Lundberg, A. Coenen, D. Konicek [34] Mapping ICNP version 1 concepts to SNOMED CT
2011 Hyeoun-Ae Park, C. Lundeberg, A. Coenen, D. Konicek [35] Evaluation of the content coverage of SNOMED CT representing ICNP seven-axis version
1 concepts
2012 Hyun-Young Kim, Hyeoun-Ae Park [42] Development and evaluation of data entry templates based on the entity-attribute-value
model for clinical decision support of pressure ulcer wound management
(continued on next page)

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J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

Table 3 (continued)

Year Authorship Study Title

Hyun-Tae Park
2006 Der-Fa F. Lu, D. Eichmann, D. Konicek, H.T. Park, P. Ucharattana, C. Delaney Standardized nursing language in the systematized nomenclature of medicine clinical
[28] terms: a cross-mapping validation method
2007 Hyun-Tae Park, Der-Fa Lu, D. Konicek, C. Delaney [31] Nursing interventions classification in systematized nomenclature of medicine clinical
terms: a cross-mapping validation
2007 Der-Fa Lu, Hyun-Tae Park, P. Ucharattana, D. Konicek, C. Delaney [29] Nursing outcomes classification in the systematized nomenclature of medicine clinical
terms: a cross-mapping validation
Amol S. Wagholikar
2011 A.S. Wagholikar, M.J. Lawley, D.P. Hansen, K. Chu [36] Identifying symptoms groups from emergency department presenting complaint free text
using SNOMED CT
Judith J. Warren
2012 J.J. Warren, E.L. Manos, D.W. Connolly, L.R. Waitman [38] Ambient findability: developing a flowsheet ontology for i2B2
2012 S.A. Matney, J. J. Warren, J. L. Evans, T.Y.Kim, A.Coenen, V.A. Auld [40] Development of the nursing problem list subset of SNOMED CT
Bonnie L. Westra
2008 B.L. Westra, R. Bauman, C.W. Delaney, C.B. Lundeberg, C. Petersen [32] Validation of concept mapping between PNDS and SNOMED CT
2017 S. A. Matney, T.Settergren, J. Carrington, R. Richesson, A. Scheide, B.L. Westra Standardizing physiologic assessment data to enable big data analytics
[49]

a
First author of each article in our sample (n = 29) are listed and the publications within our sample in which they collaborated as an author are described.

Assessment (MEA). Twenty-seven studies were ranked at stage 0 of the to achieve widespread generation of interoperable nursing data coded
modified SDLC, and two studies were ranked at stage 2 [30,42]. The nursing with SNOMED CT for use in demonstrating the impact of nur-
2007 study of Lee and Bakken [30] (stage 2) included mapping and the sing on patient outcomes. Only two of the 29 studies represented ac-
development and pre-testing of a clinical decision support (CDS) tivities beyond the stage 0 phase of the modified SDLC model and there
module to assist advanced practice nursing students in managing obe- were no studies that demonstrated the collection of nursing data coded
sity. The authors reported that SNOMED CT, CCC, International Clas- with SNOMED CT in clinical practice.
sification of Diseases (ICD-9), and the UMLS could not fully represent A form of mapping was employed in all 29 studies, however, the
all concepts of the obesity clinical practice guideline integrated into the data elements, scope, purpose, methods of mapping, and validation
CDS. The 2012 study of HY Kim et al. study [42] (stage 2) first mapped processes varied substantially. The mappings most frequently involved
pressure ulcer guidelines to SNOMED CT and then developed and tested establishing new or validating previous direct mappings or UMLS
automated templates with users under laboratory conditions. source terminology mappings to SNOMED terminology. Other studies
The scores for the MEA ranged from 2 to 8. The studies of Lee and involved validating the cross-mappings of ANA recognized terminolo-
Bakken [30], HA Park et al. [34], HA Park et al. [35], and TY Kim [47] gies including SNOMED CT in the UMLS [47] and using these to create
received a rating of 8. Thirteen studies received ratings of 6 or 7, and 10 subsets (e.g., nursing problems) of SNOMED CT coded nursing terms. In
other studies received scores of 4 or 5. Two studies received ratings of 2 fact, four studies focused on creating nursing problem list subsets for
or 3 (See Table 2). Eleven studies involved direct mapping of local or the United States [40], Denmark [45] and Netherlands [50,51] with
nursing terminologies terms to SNOMED CT to assess coverage within SNOMED CT. While the US Nursing Problem List Subset (NPLS) [40] is
SNOMED CT. A small group of studies validated previous mappings to updated regularly and available on the UMLS website [53], there were
SNOMED CT [29,31,32,41]. In four others, cross-mappings to nursing no studies that indicated use of the NPLS in the clinical setting.
terminologies and to SNOMED CT were performed [10,43,46,51]. For Eleven studies reported mapping a comprehensive set of local or
example, Hardiker et al., 2006 [10] mapped NANDA-I to ICNP to standardized terms for at least one nursing element to SNOMED CT,
compare the representation and relationships with SNOMED CT. Two with the remaining 18 the studies reporting mapping of parts. Rarely,
other studies [28,39] focused on methods for improving the ease and however, was the same process used to map (e.g. Lu studies
quality of mapping to SNOMED CT. [28,29,31]). The variability in mapping protocols raises concerns for
both redundancy in efforts and the adverse impact on standardization
when different methods are used to map. Adopting a single standard
3.6. Collaborations among authors
that is used consistently for such mappings would reduce redundancy in
effort and ensure that mappings produce reliable and valid re-
The 29 studies were first authored by 21 different researchers (see
presentations of nursing terms in SNOMED CT.
Table 3). Three of the 21 authors were first or co-author in 4 studies (TY
While 27 studies outlined potential next steps or solutions for
Kim [40,41,43,47], Matney [37,40,44,49], HA Park [33–35,42]). Four
identified issues, only nine included both recommendations and evi-
of the 21 were first author or co-author in three studies (Bakken/Henry
dence that a plan/s to carry these out were initiated. None of the plans
[24,25,30], Hardiker [10,41,43], Der-Fa Lu [28,29,31], and HT Park
included recommendations for testing the integration of SNOMED ter-
[28,29,31]). Four of the 21 collaborated in two studies (Harris [27,44],
minology coded nursing terms in electronic systems (See Appendix B).
Kieft [50,51], Warren [38,40], and Westra [32,49]). The collaborations
It was surprising to find that the studies generally did not discuss the
represent different foci across the years. For example, Suzanne Bakken
relationship or progress of the work reported toward the “creation of
collaborated in studies involving the evaluation of the ability of
interoperable nursing data.” This may indicate that the authors and the
SNOMED terminology to represent nursing terms [24,25], and a study
profession at large are unclear about the process required to produce
of the development of an electronic application to manage obesity using
standardized nursing data with SNOMED CT in electronic systems. This
SNOMED CT, among other terminologies [30].
gap in knowledge may also partly explain why the review found limited
activity beyond stage 0.
4. Discussion On a positive note the review found evidence that author groups are
actively involved in advancing SNOMED CT as can be seen in Table 3. It
This scoping review indicates that efforts are underway toward is also important to note that the nursing profession reiterated its pre-
ensuring representation of nursing in SNOMED CT. Our results suggest vious support for SNOMED CT in new position statements issued in
that these efforts, however, are young and considerable work is needed

8
J. Kim, et al. International Journal of Medical Informatics 134 (2020) 104035

2015 and 2018 [6–8,16]. The Nursing Knowledge Big Data Science data.
Initiative at the University of Minnesota is also embracing this chal- 6) Implement the formalized operational plan, funding plan, and
lenge through their efforts to incorporate SNOMED CT into a frame- timeline for achieving SNOMED CT use in practice.
work and repository for dissemination [54]. The results of this review,
however, indicate that efforts toward achieving the profession’s data Authors’ contributions
goals appear to be stymied with groups inadvertently working at cross
purposes and little emphasis being placed on the development stages JK and GK conceptualized the idea for the manuscript. JK and TM
beyond “0”. Building strong collaborations across groups that are based (1st and 2nd authors) made equal contributions to this manuscript. JK,
on a mutually accepted detailed plan for accomplishing all of the de- TM, GK, SM, and MA designed the manuscript. JK, TM, GK, RB, MS, SC,
velopmental stages (0 and beyond) required to generate interoperable DS, and RN contributed to the collection, analysis, and interpretation of
nursing data could dramatically focus and speed progress. Adoption of the data. JK, TM, and GK organized and synthetized the data. All au-
such a strategy would reduce redundancy in efforts and the timeline for thors were responsible for drafting and reviewing the manuscript con-
generating valid and reliable interoperable nursing data in electronic tent. All the authors take responsibility for the final approval of the
systems. We believe that the modified version of the SDLC can serve as version to be published.
a framework for building a detailed plan that keeps all efforts in
alignment and moving toward the generation interoperable nursing Funding statement
data.
This research did not receive any specific grant from funding
4.1. Limitations agencies in the public, commercial, or not-for-profit sectors.
Summary table
This review included only literature published in English. It also did
not capture the potential efforts of EHR vendors, hospitals, nursing
departments, chief nurse executives, nursing informaticists, and others What was already known on the topic
who may have important insights about integrating SNOMED CT but
have not published these activities. The review also did not include • The terminology Systematized Nomenclature of Medicine
Clinical Terms (SNOMED CT) contains nursing terms that
studies of SNOMED terminology use by other health disciplines.
Projects describing ongoing efforts to use SNOMED terminology (e.g., have been previously mapped to it from recognized nursing
terminologies.
•
SNOMED CT) in other disciplines can be found at SNOMED
SNOMED CT is the terminology currently supported by orga-
International website [55].
nizations to standardize nursing practice in electronic ap-
plications, such as electronic health records.
5. Conclusion
• No prior studies have actually assessed the stage of im-
plementation of SNOMED terminology (Pre-SNOMED CT
Our scoping review identified “what is known about SNOMED ter- and SNOMED CT) in nursing practice.
minology in nursing practice” in the published literature. It revealed
that efforts have been underway for nearly 25 years to ensure SNOMED What this study added to our knowledge
terminology contains sufficient nursing content for producing inter-
operable nursing data, but we found no examples of SNOMED CT use in • Arepresentation
comprehensive overview of the efforts underway to ensure
of nursing in SNOMED terminology (Pre-
practice. The literature suggests that there is no unified approach to
mapping and validation of methods and no identifiable path toward the SNOMED CT and SNOMED CT).
profession’s data goals. This lack of coordination has created re- • Athedescription of the developmental/implementation stages of
usage of SNOMED terminology in nursing.
dundancy, work that cannot be validated or reproduced, poor resource
allocation, misunderstanding, and failure to achieve SNOMED CT use in • There is no evidence of the use of SNOMED CT in nursing
practice. Considerable work is still needed to achieve
practice. Though the profession has adopted and reconfirmed its sup- widespread generation of interoperable SNOMED termi-
port for SNOMED CT [14,15], without rationale, directions and ade- nology coded nursing data.
quate resources for implementation, standards will not produce inter-
operable nursing data. Needed is an endorsed professional vision and
formalized approach to achieving SNOMED CT use in practice. These
Declaration of Competing Interest
efforts must be systematically coordinated with abundant stakeholder
engagement and adequate resources. As such, we recommend the fol-
lowing as important next steps: The authors have no competing interests to declare.

1) Create a clear and achievable professional-wide nursing vision that Appendix A. Supplementary data
elucidates the stages and activities required to achieve SNOMED CT
use in practice (e.g., modified SDLC framework). Supplementary material related to this article can be found, in the
2) Present convincing evidence that indicates the terminology stan- online version, at doi:https://doi.org/10.1016/j.ijmedinf.2019.
dards (including versioning) adopted by the profession will lead to 104035.
SNOMED CT use in practice. Endorsing government standards does not
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