Abstract
Health Level 7®’s (HL7) Fast Healthcare Interoperability Resources® (FHIR®) is leading new efforts to make data available to healthcare clinicians, administrators, and leaders. Standardized nursing terminologies were developed to enable nursing’s voice and perspective to be visible within the healthcare data ecosystem. The use of these SNTs has been shown to improve care quality and outcomes, and to provide data for knowledge discovery. The role of SNTs in describing assessments and interventions and measuring outcomes is unique in health care, and synergistic with the purpose and goals of FHIR. FHIR acknowledges nursing as a discipline of interest and yet the use of SNTs within the FHIR ecosystem is rare. The purpose of this article is to describe FHIR, SNTs, and the potential for synergy in the use of SNTs with FHIR. Toward improving understanding how FHIR works to transport and store knowledge and how SNTs work to convey meaning, we provide a framework and examples of SNTs and their coding for use within FHIR solutions. Finally, we offer recommendations for the next steps to advance FHIR-SNT collaboration. Such collaboration will advance both nursing specifically and health care in general, and most importantly, improve population health.
Keywords: interoperability, standardized nursing terminologies, quality, clinical guidelines, outcomes, HL7 FHIR
INTRODUCTION
Despite decades of EHR development and use, the healthcare industry continues to struggle with patient data management across settings and systems (interoperability) to achieve the long-anticipated use of data to improve healthcare quality and personal and population health outcomes and to discover new knowledge.1 To address this urgent need, Health Level 7®’s (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) is a healthcare interoperability standard that is being used to enable data sharing, storage, and use through uniform coding structures.2–4 FHIR can also provide a degree of data interpretation through specifying data elements such as numeric data or standardized terms.3
Since the 1970s, nurses have worked to ensure that nursing’s voice was represented in EHR data through the development of several standardized nursing terminologies (SNTs).5,6 These efforts have enabled important advances in patient care and population health.7–11 Large SNT datasets from community and acute care settings have been used for intervention effectiveness research using modern methods including data mining, natural language processing, and artificial intelligence.12–18 FHIR solutions have potential to transport and enable storage and use of SNTs for nursing assessments and interventions.3,19 Importantly, nursing assessments and interventions are pivotal for patient outcomes,20 and thus data representing them are key to understanding intervention effectiveness,16,21–23 quality improvement,24,25 and outcomes management.24,25 However, to date, synergistic solutions based on FHIR and SNTs have yet to emerge.
As FHIR is becoming the new interoperability standard for conveying meaning as well as transporting and storing data,2–4 there is an urgent need for nurses to participate in FHIR development.19 It is critical for nurses to guide the use of nursing terminologies in FHIR solutions to advance the visibility and voice of nurses, making explicit the assessments, interventions, and outcomes of nursing and other healthcare disciplines. Failing to do so will exclude nursing from realizing the benefits of a new era of the FHIR-enabled EHR. Failing to do so will also exclude important and useful SNT data from the FHIR ecosystem.
The purpose of this article is to describe FHIR, SNTs, and the potential for synergy in the use of SNTs with FHIR. We include a framework to aid in understanding how FHIR works to transport and store knowledge, and how SNTs work to convey meaning. We provide examples of SNTs and their coding for use within FHIR solutions. Finally, we offer recommendations for the next steps to advance FHIR-SNT collaboration.
BACKGROUND
FHIR is a recognized data transmission standard for healthcare information.26,27 It is free to use, offering a common set of modular components that specify healthcare information for communication or exchange regardless of how the data is stored in different healthcare systems.26,27 Many developers have worked tirelessly to contribute various components to FHIR that target clinical use cases or expand on core FHIR specifications.26,27 Scholars have demonstrated ways to use FHIR in various contexts such as clinical practice guidelines, Clinical Document Architecture (CDA) translation, and clinical wound care.19,28,29 These examples leverage the interoperability framework provided by FHIR to improve knowledge interoperability within clinical data models.30
FHIR structures
To solve interoperability challenges in healthcare, various FHIR solutions have been developed that enable coders to collaborate and rapidly expand their solutions across platforms. Two main types of FHIR solutions are resources and profiles. Resources are coded packets of information. These resources may be used to package data for exchange or storage. They are composed specifically for use cases in clinical settings.26,27Profiles are resources that are constrained or extended for use in specific circumstances. Within FHIR profiles, narrative or numerical data are embedded within coding that enables aggregation and transmission of that data (Figure 1).26,27
Figure 1.
Conceptual framework for embedding standardized nursing terminologies within HL7 FHIR profiles and resources. In this original framework, we depict the packaging of diverse reusable items. The outer structure depicts packaging comprised of FHIR Resources which package data for exchange or storage; as defined by APIs, or codes that specify how healthcare information can be communicated. Within this packaging, we depict FHIR profiles as hexagonal shapes which specify transmission or storage of resource/API content in specific circumstances. Within FHIR profiles are shapes depicting standardized nursing terminology data. Note that resources and profiles can also store or transmit unstandardized content such as free text, potentially losing data integrity. API: application programming interface; FHIR: fast healthcare interoperability resources.
For example, the FHIR resource “PlanDevelopment” provides specifications for profiles related to planning (eg, order sets, care plans, or protocols).26,27,31 Thus, FHIR resources and FHIR profiles provide the coding, or packaging, within which data elements become interoperable “liquid data” and may be transported, stored, and used in the real world.32
Use of clinical knowledge representation standards within FHIR is encouraged to ensure robust data transmission and reduce bias and synonymy in data.19,29,30,33,34 The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC) are 2 of several external coding systems used with FHIR.33,34 Standardized nursing terminologies currently exist within SNOMED CT and LOINC; thus, the structures needed for embedding SNTs within FHIR solutions exist.33,34
Standardized nursing terminologies
The active American Nurses Association (ANA)-recognized SNTs are defined in UMLS as in Table 1. The main elements of SNTs are standardized assessments (diagnoses), interventions (care plans), and outcomes (rating scales) that capture the domain of health and healthcare.35 The UMLS, or Unified Medical Language System within the National Library of Medicine, is a source for many health and biomedical vocabularies and standards, including SNOMED CT, LOINC, and the SNTs.36
Table 1.
Unified medical language system (UMLS) descriptions of American Nurses Association (ANA)-recognized standardized terminologies
| Terminology/nursing standards development organization | Components | Description |
|---|---|---|
| Clinical Care Classification (CCC) formerly Home Health Care Classification (HHCC)37–39/HCA Healthcare |
|
Standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other health care settings |
| The International Classification for Nursing Practice ICNP(r)40,41/International Council of Nursing |
|
A combinatorial terminology, using a multiaxial structure of precoordinated concepts to represent observations and procedures |
| NANDA-I42,43/NANDA International |
|
Used to describe patients’ responses to actual or potential health problems and life processes responses to diseases |
| The Nursing Interventions Classification (NIC)44,45/The University of Iowa Center for Nursing Classification and Clinical Effectiveness (CNC) |
|
Names and values for procedures/orders/service intent related to the treatment activities of nurses and other providers |
| The Nursing Outcomes Classification (NOC)46,47/The University of Iowa Center for Nursing Classification and Clinical Effectiveness (CNC) |
|
Patient, family, and community outcomes developed to evaluate the impact of interventions provided by nurses or other health care professionals |
| The Omaha System (multidisciplinary)48,49/Martin Associates, Omaha, NE |
|
Standardized terms, definitions, and codes for client problems, multidisciplinary interventions, and problem-specific client outcomes |
Examples of standardized nursing terminologies within FHIR profiles
Below, we illustrate the feasibility of SNT use within FHIR profiles through examples for assessments (diagnoses), interventions (care plans), and outcomes (rating scales).35 These examples reflect various scenarios in health care to illustrate how SNTs may be used within FHIR by informaticists and others to maximize the potential of FHIR in nursing and healthcare. We accessed these SNOMED CT- and LOINC-encoded examples freely on-line using SNOMED CT browsers or in other published materials. In each example we provide a brief description of the featured SNT structure.
Assessments
Standardized nursing terminologies represent nursing’s comprehensive, holistic perspective of health that encompass bio-psycho-social-spiritual elements, including the social determinants of health, augmenting traditional biomedical diagnoses and procedure codes.35–49 Such data are valuable and could be systematically used within FHIR to specify important information otherwise not accessible to care providers.12,15,21
Omaha System
The Omaha System has a standardized, defined problem list of 42 problems, each with taxonomically associated signs/symptoms. This encoded example shows Communication with community resources problem signs/symptoms such as language barrier, transportation barrier, and cultural barrier (Figure 2).49 The Communication with community resources problem is 1 of 8 problems deemed core for social determinants of health assessments (eg, Income, Residence, Mental health, and Substance use).25 A modular SNT profile approach could be used to ensure appropriate assessment and documentation of applicable problems, streamlining standardized social determinants of health assessments across populations and settings.
Figure 2.
Signs/symptoms of the Communication with community resources problem. Codes are provided for SNOMED CT concept ID and the Omaha System (in parentheses).
Clinical Care Classification
The CCC assessments identify nursing diagnoses. The CCC of 528 nursing outcomes uses 3 outcome qualifiers to depict the 3 possible conditions/stages for each diagnosis. This encoded CCC example provides an approach in which data for multiple repeated assessments are intended to show changes over time.37,38 For example, the CCC activity intolerance risk is embedded within LOINC as follows. This approach could be used to track activity tolerance risk over time for various populations or settings.
28082-6 Activity intolerance risk
Improved LA65-8
Deteriorated LA66-6
Stabilized LA6635-2
NANDA-I
The current structure of NANDA-I nursing diagnoses is referred to as Taxonomy II and has 3 levels: Domains (n = 13), Classes (n = 47), and Diagnoses (n = 237). It is possible to search SNOMED CT for NANDA-I diagnoses.42 For example, a search for the NANDA-I nursing diagnosis “disturbed sleep pattern” returns the SNOMED CT concept “sleep pattern disturbance” with the SNOMED CT ID = 26677001. This could be used to document and gather data on sleep pattern disturbance to guide clinical practice and to identify sleep issues for various groups or situations.
Interventions and care plans
Care planning is a prime example in which nursing interventions may be inserted as a standardized text description for interventions (with associated SNOMED CT and terminology coding) into FHIR profiles.31 Coding care planning with FHIR in the same manner as order sets are currently coded in FHIR profiles would prompt consistent application of appropriate interventions for the care of particular patients; thus potentially improving care quality.31 Often interventions/care plans are documented with local codes or as free text within EHRs, or are only available in a separate module from nursing assessments and other nursing documentation. FHIR care plan resources using evidence-based guidelines encoded with SNTs offers an alternative to these approaches that would generate useful, standardized data while guiding care.30,48,50–53 All SNT intervention examples below could be used to guide and document nursing or multidisciplinary interventions, and within FHIR profiles to generate, transmit, and store data to evaluate care quality.
Omaha System
The Omaha System has defined terms for 4 intervention actions (categories) and 75 intervention targets that are used in combination to describe evidence-based interventions that address any of the 42 problems. In the Enhanced Recovery After Surgery Hip and Knee Replacement Recovery Guideline, there are 23 interventions addressing 10 problems (Figure 3).50,51 Each Omaha System intervention addresses a defined problem and includes 2 additional standardized terms (category and target) and a nonstandardized custom term that further specifies guideline content (care description). For example, the first intervention in the guideline is Circulation (problem term)-Surveillance (category term)-laboratory findings (target term)-Assess for signs of preoperative anemia (care description). For each intervention there is an Omaha System code for the problem which is mapped to a SNOMED CT code; and a single SNOMED CT code for the combined category and target terms, with separate Omaha System codes for the category term and the target term.50,51
Figure 3.
The enhanced recovery after surgery hip and knee replacement recovery guideline. Codes are provided for SNOMED CT concept ID and the Omaha System (in parentheses). Interventions address 10 problems. They are shown as linked category-target-care description terms, followed by coding. Within SNOMED CT, each category-target combination has a single SNOMED CT code.
International Classification for Nursing Practice
The ICNP contains over 4200 terms organized in 7 axes used as neutral building blocks for creating precoordinated concepts. Like the Omaha System, ICNP interventions for promoting family functioning in ICNP and SNOMED CT are mapped as follows, with a single ICNP code for the intervention which is mapped to a corresponding SNOMED CT concept ID. The ICNP code is shown in parentheses following the SNOMED CT code.52,53
Promoting effective coping
Coding: SNOMED CT=385722003 (10035936)
Promoting effective family communication
Coding: SNOMED CT=710146004 (10036066)
Promoting effective family process
Coding: SNOMED CT=710147008 (10036084)
Promoting effective parenting
Coding: SNOMED CT=38638300 (10032496)
The Nursing Interventions Classification
The NIC consists of 433 different interventions that exist within 27 classes that are further grouped within 6 domains.44,45 As with NANDA-I, is possible to search SNOMED CT browsers for NIC interventions. In this example, the intervention preparatory sensory information is named as such and encoded as SNOMED CT ID = 386396004. These examples demonstrate that clinical nursing guidelines have been encoded using SNTs and mapped to SNOMED CT codes that currently exist and could be embedded with FHIR care plan resource frameworks.44,45
Outcome measurement
Outcomes are measures that are sensitive to nursing interventions.46,48 Coding outcomes is one of the important reasons FHIR and other standards exist; that is, for the expected and desired use of data to track outcomes of care and to improve care quality.46,48 These observations could be encoded in the way that blood pressure is encoded within FHIR.54 This blood pressure example shows how LOINC codes are embedded within a FHIR blood pressure example:
“5.1.1.3 Blood Pressure Example
There must be 2 components (systolic and diastolic)
The systolic has LOINC code 8480-6, and a quantity
The diastolic has LOINC code 8462-4, and a quantity
Other components are allowed (posture, etc., but not profiled in the base blood pressure profile).”54
We present examples of outcome measures from the Omaha System and NOC that include both SNT codes and LOINC codes.46,48 FHIR profiles could be developed for these outcome measure regardless of terminology for data interoperability, exchange, storage, and use.
Omaha System
For the Omaha System, each of 42 problems has Knowledge, Behavior, and Status ratings (Likert-type ordinal scales from 1 [lowest] to 5 [highest]).48,49 These scales each have specific LOINC codes by problem as in the Circulation problem example below. This data could be used to track the patient’s knowledge, behavior, and status for Circulation-related problems over time, and to monitor the acuity of a caseload or population regarding Circulation issues at any given time.
Assess Circulation:
Circulation Knowledge [OMAHA] Coding LOINC=28255-8
1=no knowledge
2=minimal knowledge
3=basic knowledge
4=adequate knowledge
5=superior knowledge
Circulation Behavior [OMAHA] Coding LOINC=28254-1
1=not appropriate behavior
2=rarely appropriate behavior
3=inconsistently appropriate behavior
4=usually appropriate behavior
5=consistently appropriate behavior
Circulation Status [OMAHA] Coding LOINC=28256-6
1=extreme signs/symptoms
2=severe signs/symptoms
3=moderate signs/symptoms
4=minimal signs/symptoms
5=no signs/symptoms
The Nursing Outcomes Classification
The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome.46,47 This NOC example is used in nursing assessments of fluid balance.
Assess Fluid Balance:
Fluid Balance Coding LOINC=9097-7
1 = severely compromised
2 = substantially compromised
3 = moderately compromised
4 = mildly compromised
5 = not compromised
This data could be used to track the patient’s fluid balance assessments over time, and to monitor the nurses’ assessments of fluid balance in a unit or hospital system at any given time.
DISCUSSION
In this article, we assert the value of and need for SNTs to be used within HL7 FHIR for assessments, care planning, and outcomes measurement. Currently nursing is one of many disciplines acknowledged by FHIR.26,27 It is time for nursing’s contributions to health care assessments, interventions/care plans, and outcomes to be systematically represented in FHIR. Standardized nursing terminology assessment, intervention, and outcome data have been useful to health care clinicians in examining intervention effectiveness for nurses and other disciplines.11 Once embedded within FHIR profiles the known SNT benefits can be realized: more comprehensive assessments, better intervention descriptions, and clearer, more pertinent outcomes measurements; the data from which all lead to improved data transmission, storage, and knowledge discovery in nursing and population health.11
Recommendations
Create a formal shared agenda for FHIR-SNT collaboration. We call for nursing standards development organizations (Table 1) and all nursing informatics organizations (eg, Alliance for Nursing Informatics [ANI]),55 American Academy of Nursing Expert Panel on Informatics & Technology,56 American Nursing Informatics Association (ANIA),57 AMIA Nursing Informatics working group (NI WG),58 European Federation for Medical Informatics-Nursing Informatics (EFMI-NI),59 Healthcare Information and Management Systems Society Nursing Informatics (HIMSS),60 and the International Medical Informatics Association Nursing Informatics Special Interest Group (IMIA NI)61 to join in a shared agenda to expand SNT-FHIR efforts. This shared agenda should be formalized and advanced within an existing standards organization such as the UMLS.36
Identify technology partners and funding sources. To advance FHIR-SNT efforts requires domain knowledge as well as coding expertise; therefore, nursing organizations should identify and collaborate with capable partners in the technology/coding sector. Funding sources to engage technology/coding partners should be identified.
Leverage the formal HL7 “FHIR Community Process” (FCP). 62 The FCP is intended to enable representation of overlapping and diverse stakeholders, approaches, and value propositions.62 The FCP participant organizations that wish to adapt FHIR for specific use cases such as SNT documentation would be able to work with different parts of the overall FHIR Community. They may create subcommunities that work together to solve interoperability problems using FHIR. For example, nursing standards development organizations may develop FHIR implementation guides.62 The FCP provides a set of guidelines to be followed by any kind of community to aid in using FHIR to address data transmission and storage challenges. Organizations follow the FCP in order to produce output that works with what the rest of the community is producing and has better acceptance and uptake by the community.62
Jointly create FHIR-SNT profiles. The goal of this shared agenda should be to jointly create FHIR profiles within which any SNT assessment, intervention/care plan, or outcome measure regardless of terminology may be packaged for interoperability, exchange, storage, and use. As illustrated in the examples above, all SNTs have potential for use within FHIR profiles and could benefit from and contribute to this shared agenda.
Leverage FHIR resources such as Resource PlanDefinition. 63 This resource allows for the definition of various types of plans as sharable, consumable, and executable artifacts. It is general enough to support the description of a broad range of clinical artifacts such as clinical decision support rules, order sets, and protocols. This is an ideal resource for SNT-FHIR care planning profile development for evidence-based guidelines or patient care plans.63
Nursing informatics specialty organizations and leaders are newly arrived in FHIR,19,28,29 and beginning to take an active role in FHIR communities. These recommendations offer a roadmap for nursing’s first steps towards meeting the challenge of SNT data transmission, storage, and use in nursing and healthcare in the FHIR era.
CONCLUSIONS
The role of SNTs in describing assessments and interventions and measuring outcomes is unique in health care, and synergistic with the purpose and goals of FHIR. The examples presented in this article illustrate ways for nursing and health care clinicians and informaticians to use SNTs with FHIR. The recommendations offer a possible roadmap for next steps in FHIR-SNT collaboration. The goal is to increase potential for knowledge discovery within the FHIR data ecosystem using high quality standardized data that includes nursing’s comprehensive, holistic worldview, toward improving health care quality and population health. Existing FHIR communities and processes await nursing’s perspective and intelligence to advance this effort.
Contributor Information
Karen A Monsen, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.
Laura Heermann, Logica, Salt Lake City, Utah, USA; College of Nursing, University of Utah, Salt Lake City, Utah, USA.
Karen Dunn-Lopez, College of Nursing, University of Iowa, Iowa City, Iowa, USA.
FUNDING
This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
AUTHOR CONTRIBUTIONS
The first author (KAM) drafted the manuscript. All authors (KAM, LH, and KDL) reviewed and edited the manuscript and revisions thereof.
CONFLICT OF INTEREST STATEMENT
None declared.
DATA AVAILABILITY
Not applicable.
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