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

Abstract:

BACKGROUND:Currently, it is rare for nursing data to be available in data repositories due to the quality of nursing data collected in clinical practice. To improve the quality of nursing data, the American Nurses Association recommends the use of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for coding nursing problems, interventions, and observations in electronic health records. OBJECTIVE:To determine "what is known about the use of SNOMED terminology (Pre-SNOMED CT and SNOMED 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 terminology. 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.

journal_name

Int J Med Inform

authors

Kim J,Macieira TGR,Meyer SL,Ansell Maggie M,Bjarnadottir Raga RI,Smith MB,Citty SW,Schentrup DM,Nealis RM,Keenan GM

doi

10.1016/j.ijmedinf.2019.104035

subject

Has Abstract

pub_date

2020-02-01 00:00:00

pages

104035

eissn

1386-5056

issn

1872-8243

pii

S1386-5056(19)30889-5

journal_volume

134

pub_type

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