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The Current State of Data and Information Sharing in Nursing

Data and information sharing in the nursing profession is hampered due to inconsistent use of data standards and terminologies. Cross-system interoperability is seriously limited and results in the lack of comparability and consistency of nursing data. This inconsistency also results in inefficiencies and inaccuracies in local, regional, and national data reporting. Since there are no agreed upon principles for which data standards and nursing terminologies should be used, nursing documentation remains inconsistent even within a single hospital that has adopted a single nursing terminology. With inconsistent documentation and lack of standards, nursing data cannot consistently be used for quality measurement or improvement.

Recommendation to Advance Standardization of Nursing Data for Improved Care

The American Nurses Association (ANA) has recognized 12 terminologies for use in nursing, and nurses have worked to determine a single “best” terminology for clinical documentation (Rutherford, 2008).

The International Classification for Nursing Practice (ICNP) is a nursing terminology that represents an international standard for facilitating the description and comparison of nursing practice locally, regionally, and nationally. ICNP was developed and advanced with input from the International Council of Nurses, Health Ministries, the World Health Organization (WHO), the International Health Terminology Standards Development Organization (IHTSDO), SNOMED CT, the Clinical Care Classification (CCC) from SabaCare, the Community Nursing Data set from the National Health Service (NHS) in Scotland, and the Canadian Health Outcomes for Better Information and Care (C-HOBIC). (Coenen et al., 2015)

The IHTSDO is a not-for-profit organization based in Denmark that develops and maintains SNOMED CT, which serves as an international, interdisciplinary healthcare terminology. The current focus of ICNP is to harmonize nursing terms (diagnosis/problem lists, and interventions) into WHO International Classifications for Disease (ICD), and SNOMED CT (Coenen, et al., 2015).

SNOMED CT® and LOINC® serve as international terminologies that can link interdisciplinary healthcare terminology both nationally and internationally. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world which integrates, through external mappings and concepts from many nursing terminologies. (Hardiker, et al., 2015)

The development within the United States of the Nursing Management Minimum Data Set (NMMDS) provides 18 elements organized into three categories: environment, nursing care resources, and financial resources. The environment and nursing care categories for the NMMDS have been normalized to national data definition standards, and incorporated into LOINC®. (Regenstrief Institute, 2014) Consequently, most elements of the NMMDS are available through implementation of the LOINC® standard, making comparative analysis of these nursing variables and inclusion in outcomes analysis more efficient. (Hardiker, et al., 2015) In addition, many assessment scales used in evidence-based guidelines, such as the Braden Scale for pressure ulcers, the Morse Fall Scale, and several pain scales are already integrated into LOINC®.