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Intermountain Healthcare

Although standardized terminologies are recommended, it is known that the solution to the specificity of those terms is in the development of detailed clinical models (DCM) that define the structures of the clinical content. As we move toward electronic documentation, it is important to incorporate structured data into clinical nursing workflow using DCMs and standard terminologies. This provides opportunities to use consistent data and ultimately support improved outcomes for patients. One example is the work of the Clinical Information Modeling Initiative (CIMI) which has developed guidelines for the creation of the DCMs (Coyle, et al, 2003). These guidelines provide a common format for representing clinical content so that it is interoperable and can be shared.

During the Nursing Knowledge: Big Data and Science for Transforming Health Care Conference hosted by the University of Minnesota, School of Nursing, Matney presented a model for decubitus ulcers that is included in the Unified Modeling Language System (UMLS) (University of Minnesota, School of Nursing, 2014). In this model, SNOMED CT® and LOINC® are used for nursing documentation, thus leading to standardized nursing data so they can measure performance, learn from the data and improve outcomes for patients with decubitus ulcers. Through standard terminology mapping into SNOMED CT® and LOINC®, this model demonstrates that converting the terms to knowledge can aid in decision making for nurses. The model was evaluated by Intermountain Healthcare, Aurora Health System, Partners Healthcare, Mayo, Veterans Affairs (VA), and Kaiser Permanente. (Harris, et al., 2015) The ultimate goal is improved outcomes in care of patients with decubitus ulcers based upon evidence-based nursing models.