INFORMATICS THEORY

Health care data standards

OBJECTIVE
1. Define data standards in the healthcare profession point of view.
2. Differentiate syntax from semantics.
3. Enumerate categories of standards.
4. Cite organizations dedicated to standardization of healthcare data.
5. Describe the impact of standardizations of healthcare data.
6. Understand the basics of nursing minimum data set.
7. Correlate nursing terminologies and relevance to nursing practice.
8. Identify components of advanced technology systems in nursing.
HEALTH CARE DATA STANDARDS

CATEGORIES OF STANDARDS

Two Important Concept

SYNTAX

Refers to structure of communication.

SEMANTICS

Convey the meaning of communication.

HEALTH CARE DATA STANDARDS

CATEGORIES OF STANDARDS

DATA EXCHANGE/MESSAGING STANDARDS

Allow transactions to flow consistently between
systems or organizations because they contain
instructions for format, data, elements, and structure.

TERMINOLOGY STANDARDS
Vocabularies that provide specific codes for clinical
concepts such as diseases, problem list, allergies,
medications, and diagnoses that might have varying
textual descriptions in a paper chart or a transcription.
HEALTH CARE DATA STANDARDS

CATEGORIES OF STANDARDS

DOCUMENT STANDARDS
Indicate what type of information is included in a
document and where it can be found.

CONCEPTUAL STANDARDS
Allows data to be transported across systems
without losing meaning and context.
HEALTH CARE DATA STANDARDS

CATEGORIES OF STANDARDS

APPLICATION STANDARDS
Determine the way business rules are
implemented and software systems interact.

ARCHITECTURE STANDARDS
Define the process involving in data storage and
distribution.
HEALTH CARE DATA STANDARDS
ORGANIZATIONS

 Healthcare organizations: Service delivery entities,

Regulators, Vendors and Consultants.
 Standards development involves technical
committee that defines methods, and groups organized
around the communities of interest.
 Stakeholders in Development projects: Clinicians,
Researchers, Bio-Informaticist, Chief Information
Officers, Database Administrators, Information
Systems Analyst, and Project Managers.
 Special interest entities in public health, patient
safety, and electronic health records work to ensure
that the standards are relevant to practice in those
areas.
HEALTH CARE DATA STANDARDS

NURSING MINIMUM DATA SET

ELEMENTS

Nursing Care Elements

Nursing Diagnosis Intensity of Nursing Care

Nursing Intervention

Nursing Outcome
HEALTH CARE DATA STANDARDS

NURSING MINIMUM DATA SET

ELEMENTS

Patient Demographic Elements

Personal Identification Race/Ethnicity

Date of Birth Residence

Sex
HEALTH CARE DATA STANDARDS

NURSING MINIMUM DATA SET

ELEMENTS

Service Elements

Unique Facility Termination Date

Unique Patient Health Record Disposition of patient
Unique # of principle RN
Episode Encounter Date
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

Nomenclatures

Terms or labels for describing concepts in nursing

such as diagnoses, interventions and outcomes.

Classifications

Ordering of entities, including nomenclatures, into

groups or classes on the basis of their similarities.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

Taxonomy

Study of classification and simultaneously refers to

the end product of classification.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES
NANDA
Describe a patient's reactions to the disease and to
treatment.
NIC
A standardized language for treatments that nurses
perform.
NOC
It goes beyond the work of NIC toward classification
of outcomes useful in clinical nursing.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES
OMAHA SYSTEM
It covers some of the same ground as the NANDA
nursing diagnoses, and incorporates the Nursing
Minimum Data Set (NMDS).
SABA’s HOME HEALTHCARE

The Home Health Care Classification of Nursing

Diagnoses and Interventions (HHCC), developed at
Georgetown University, focuses on community
health.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES
UMLS METATHESAURUS

Includes terms from NANDA, NIC, NOC, HHCC, and

others.

CCC
 A standardized, coded nursing terminology that
identifies the discrete elements of nursing practice.
 Provides a unique framework and coding
structure for capturing the essence of patient care in
all health care settings.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES
PNDS
Describes perioperative nursing practice with a
sub-set of terms that specifically describe
perioperative nursing diagnoses, nursing
interventions, and patient outcomes in surgical
settings from pre-admission until discharge.
SNOMED CT
Considered to be the most comprehensive,
multilingual clinical healthcare terminology in the
world.
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES
PCDS (version 4.0, 1998)
Contains a data dictionary and sets of terms and codes
representing specific values of Patient Problems (363 terms),
Patient Care Goals (311 terms), and Patient Care Orders
(1357 terms).
INTERNATIONAL CLASSIFICATION FOR
NURSING PRACTICE
Is a combinatorial terminology for nursing practice developed
by the international nursing community under the
sponsorship of the International Council of Nurses (ICN).
HEALTH CARE DATA STANDARDS

NURSING TERMINOLOGIES

STANDARDIZED TERMINOLOGIES

NURSING MANAGEMENT MINIMUM DATA SET

Data variables categorized into environment, nurse

resources, and financial resources that are needed
to inform the decision making process of nurse
executives related to leading and managing nursing
services delivery and care coordination.
HEALTH CARE DATA STANDARDS

CONCEPT ORIENTED TERMINOLOGY

HEALTH CARE DATA STANDARDS

CONCEPT ORIENTED TERMINOLOGY

Terminologies defining relationships

Concept
Thought or reference; unit of knowledge created by a
unique combination of characteristics (an abstraction
of a property of an object or of a set of objects.)

Term
the symbol; verbal designation of a general concept
corresponds to two or more objects which form a
group by reason of common properties.
COMPONENTS OF ADVANCED TERMINOLOGY SYSTEMS

CONCEPT ORIENTED TERMINOLOGY MODEL

Representing Language
Ontology Language
•Represents classes and their properties.
•Are able to support, though explicit semantics, the
formal definition of concepts in terms of their
relationships with other concept.
Computer-based Tools
Representation language may be implemented using
description logic within a software system or by a
suite of software tools.
HEALTH CARE DATA STANDARDS

CONCEPT ORIENTED TERMINOLOGY

Terminologies defining relationships

Objects

the referent; anything perceivable or conceivable.

COMPONENTS OF ADVANCED TERMINOLOGY SYSTEMS

CONCEPT ORIENTED TERMINOLOGY MODEL

Terminology Model

Schemata
Incorporate domain-specific knowledge about the
typical constellation of entities, attributes and events
in the real world and reflect plausible combinations of
concepts.
Type Definitions
Obligatory conditions that state only the essential
properties of the concept.