A NANDA representative attends the Nursing Terminology Summit held each summer at Vanderbilt University, Nashville, TN. This conference promotes the development and use of data standards. Given the advances being made in healthcare informatics and infrastructure development, such work is fundamental to nursing terminology implementation. I attended the July 2003 conference. Participants requested the Steering Committee to write a statement that summarizes the work of the Summit for the nursing profession and provides a brief overview of the role and function of the major standards organizations that impact nursing. The following represents their report.

Health Care Data Standards

As electronic communications and data storage become increasingly the norm in health care, as in other aspects of life, national and international efforts around the world are seeking to establish a robust infrastructure for Healthcare information. A key component of this infrastructure is healthcare data standards. These standards, with proper security to protect private information, will make it possible for healthcare providers to share information for the patient’s benefit, even when the information is in a different site or a different computer system. Use of such standards will increase patient safety, promote quality improvement, and facilitate clinical research based on patient care records. Standards for data and other aspects of information systems will also make it easier to track information for public health purposes - for early detection of disease outbreaks, for example, or for assessing effectiveness of a health promotion initiative.

The standards will affect all aspects of health care - medicine, nursing, dentistry, veterinary practice, ancillary services, administration, payment, and public health. Healthcare data standards are developed and recognized through independent, voluntary organizations. Some prominent ones include:

* The International Standards Organization (ISO), which uses democratic processes to establish worldwide standards for everything from photographic film to health care terminology. Technical Committee 215 of ISO is responsible for health care data standards.

* Technical Committee 251 of the European Standards Committee (Comitee Europeen de Normalisation [CEN]), which sets standards for health information in the European Union.

* Health Level 7 (HL7), which sets standards for electronic messages about all types of health information.

* The Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT), a division of the College of American Pathologists, which represents health care concepts and the relationships among them.

* Logical Observation Identifier Names and Codes (LOINC), which sets standards for identifying laboratory tests and other clinical observations.

Reference Terminology: An Essential Standard

Among the many kinds of standards for healthcare data, an important one is “reference terminology.” Usually when nurses refer to standardized language, they mean the verbal expressions used in documents or computer systems to communicate among themselves and with other healthcare providers about nursing care. Reference terminology, by contrast, refers to the concepts and relationships necessary to define something (such as a nursing diagnosis or action), presented according to some formal set of rules about how to depict the concepts and relationships in models. In much the same way as a sentence diagram depicts the roles and relationships of the words in an English sentence, a reference terminology model shows how the defining components of a nursing diagnosis or action relate to one another. In both cases, the diagram or model removes ambiguity that may be present in the more usual vernacular expression.

Just as no one would want to read a paragraph composed of diagrammed sentences, no human would want to read a health record composed entirely of modeled reference terminology. Computers, however, can be programmed to be quite good at reading reference terminology. In fact, they can process reference terminology more accurately and “understand” its meaning better than they can everyday language. For this reason, many sets of terms that are used widely in health care-including, among others, ICD codes, CPT codes used in the United States to record medical procedures, and nursing languages recognized by the American Nurses Association - have been “modeled” within SNOMED Clinical Terms. In computer systems used to process health information for the National Health Service in the United Kingdom, and increasingly in the United States, humans will use familiar language on the screens to record and communicate, while SNOMED CT will operate behind the scenes to be sure that computer systems understand and process the information correctly.

Promoting Reference Terminology for Nursing: The Summit Conferences

To get the standards right, each professional discipline must set the standards for the information its practitioners collect and record in providing or managing patient care or public health services. A series of Nursing Terminology Summit Conferences held annually since 1999 at Vanderbilt University in. Nashville, TN, USA, has promoted and contributed to standards for nursing information not only in the United States but internationally.

Communication is the backbone of progress. To adapt, change, or develop requires incorporating the spirit and artful skills of communication into every step of a plan. As perioperative nurses, we realize the value of communication as we attempt to explain the importance of the nursing care role to administrators, legislators, students, peers, and others who query our roles and responsibilities. Nurses assess, interpret, make decisions, and evaluate daily as they implement care. They coordinate, collaborate, and optimize while working to establish a trusting and caring environment with team members. Translating those activities into words that describe patient care and that can be quantified and used to explain what a perioperative nurse does each day without offering an endless list of tasks is the ultimate challenge.

Describing perioperative patient care is difficult for many reasons, including that activities occur within restricted time frames and result from decisions and monitoring by many people at once. Even nurses who realize and believe that nursing is an important component of the care continuum during surgical and other invasive procedures have difficulty understanding and explaining how their roles, responsibilities, and nursing care activities are integrated in a highly technical environment. Overcoming various interpretations, role confusion, and inconsistent use of language, when also attempting to compare and measure nursing care, requires a common spoken and written language and consistent messages.

LEARNING THE LANGUAGE

When someone asks what care perioperative nurses provide, the first instinct is to describe tasks. Easy responses might include “assist the surgeon” or “ensure that supplies and equipment are ready and working.” These responses send a message to others about the value of the intraoperative nurse in patient care roles. They also confuse the issue when other health care providers claim that they are providing the same care and participating in the same activities.

The challenge is to identify the best way to describe the patient’s problems and associated care using nursing language, not a list of tasks. The language must be consistent with the knowledge necessary to determine patient needs associated with the task. For example, applying an electrosurgical dispersive pad is considered an intraoperative task. It is performed several times each day in many locations where surgical procedures take place, usually without adverse outcomes. Translating that task into nursing language requires understanding the equipment’s use and function, as well as patient needs associated with using electrosurgical units (ESU) and associated devices. Applying the electrosurgical pad seems to be a routine, harmless activity because of the warning signals built into the equipment and guidelines for its use (eg, presence of implants, appropriate pad size, presence of muscle tissue, absence of scarring, proximity to the incision). We even make it seem harmless by spending very little time discussing the ESU during orientation. After all, what does a person need to know about applying an electrosurgical dispersive pad when it is so easy?

Information and knowledge needed to use the ESU is more comprehensive than it seems and should not be taken for granted. Patient considerations, such as compromised skin and tissue integrity (eg, dryness, scaling, excess sweating, lesions), a procedure that might vary from the standard approach (eg, different incision, different skin prep site), or changing positions throughout the procedure, can be identified during the nursing assessment and result in. patient-specific interventions and evaluations to prevent adverse outcomes associated with the task. This requires nursing assessment, as well as knowledge of the equipment and its function. What other person in the room has this understanding?

There is an unlimited number of tasks that can be identified and associated with nursing knowledge. Applying compression devices, tourniquets, or dressings; using positioning devices; monitoring urinary output; having safety equipment available; preparing equipment for a difficult intubation; decreasing the length of surgical procedures; and classifying wounds are activities managed every day by care providers who do their jobs without thinking about how they are preventing adverse outcomes because of the knowledge they provide during patient care. Nursing knowledge plays a role in these and many other responsibilities in health care settings.

OVERCOMING COMMUNICATION BARRIERS

Nursing language is not new. Every educational program attempts to help students understand and use the nursing process; however, when students select an OR career, the language changes from one of assessment, diagnosis, intervention, evaluation, and outcomes to one that revolves around a medical diagnosis and surgical procedures. Those of us who learned perioperative patient care understand this because proving oneself in an OR means efficiently and effectively doing multiple tasks with minimal direction or assistance. In the eyes of team members, however, this may mean that completing tasks is seen as comparable to providing nursing, care.

WASHINGTON — Ever hear a patient say that he or she is “feeling evil” and let the remark go by without comment? If so, an opportunity might have been missed to diagnose depression, Dr. Annelle Primm said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

Minority cultures have different ways of expressing depression. Latinos may speak of “having nerves”; Asians, of being “out of balance”; and African Americans, of “being angry,” said Dr. Primm of Johns Hopkins University, Baltimore. “This often gets overlooked as a mental health issue,” she said.

Dr. Primm recently produced a video, “Black and Blue: Depression in the African American Community,” which includes interviews with depression experts as well as African Americans who have the disease. One expert, Edgar Wiggins, director of Baltimore Crisis Response, noted that being an African American with depression carries a double stigma: that associated with mental illness and with being African American.

Culture plays a strong part in whether minority patients decide to get help, said Dr. Primm, who also serves as director of the American Psychiatric Association’s department of minority/national affairs. For example, in the black community, religion plays a big role. “Many people believe their depression is caused by a lack of faith or by not praying hard enough,” she said in the video. Several patients responded that they did pray before and during their illness but that they also sought other sources of help.

African Americans are less likely to seek help for depression, but they are more likely than are whites to be exposed to stressors such as poverty, racism, and violence that put them at a higher risk of developing the condition, Dr. Primm said. They also have higher rates of illness and death from heart disease, stroke, diabetes, and AIDS–and that also puts them at a higher risk of depression, she added.

Because FIPSE is so well known for its support of innovation and reform in numerous other areas, few outside of the education field have appreciated the centrality of its role in sponsoring innovations in the medical and health sciences. These changes have been varied and far reaching, and they have addressed some of the basic concerns about the provision of health services and medical training in this country. Some were motivated by notions that health service providers can be poor communicators or lack empathy. Others focused on the problem of assessing clinical competencies, exacerbated by concerns of the patients upon whom students practiced their new skills. Still others arose from the perception that the specific health needs of some groups were not receiving enough attention.

The demand to better prepare health-care providers in these and other areas collided with a curriculum that has exploded with so much content that it is often unmanageable–even while many are urging the addition of new content and altered pedagogy to provide more relevant learning and to motivate students to become more active participants in the learning process. And all of these demands come at a time when diminished funding within the health sciences has made innovation difficult.

FIPSE’ s role in supporting change has therefore been vital. But why FIPSE? Because no one else offers significant funding for research and innovation in medical and health education. The National Institutes of Health (NIH) has had and continues to have an essential and respected role in funding fundamental and clinical research in medicine and health, but support of education has not been part of its mandate. From its founding onward, the National Science Foundation (NSF) has supported science education, including pre-medical education, but as a matter of policy excludes the applied clinical sciences from all of its funding programs. So there is no agency other than FIPSE whose primary mission includes support for change in medical and health education.

By the end of its first decade, FIPSE was already a major player in bringing about far-reaching changes in medical education. Foremost among several such efforts was a sequence of projects, first funded in 1980, that invented, implemented, and refined a revolutionary new methodology to assess the clinical skills of medical students, physicians, and practitioners in many health disciplines. That technique–the use of standardized and simulated patients (trained lay people or actors who present or simulate particular disorders or symptoms) as expert assessors–is by now familiar to medical students and other would-be health-care professionals throughout the world.

A decade later, in 1993, another watershed was reached when FIPSE funded a series of initiatives to integrate women’s health throughout the medical curriculum, first, and throughout the curricula of the other health sciences later. Before then, research data from male subjects was extrapolated to females–except of course for reproductive differences–and there was thought to be no need for special attention to non-reproductive women’s health in medical training. But FIPSE had the vision and multifaceted experience needed to take on the issue of women’s health in medical education, as it had earlier embraced the new idea that lay people could become skilled teachers and evaluators in medical and health science.

The remainder of this article will discuss in depth these two landmark medical projects supported by FIPSE and will conclude by mentioning a few other significant FIPSE efforts that have been–or still promise to be–influential in the fields of medical and health education.

STANDARDIZED PATIENTS AND THE ASSESSMENT OF CLINICAL SKILLS

The Problem: Traditionally, new doctors’ progress through medical school and entry into the profession have both been governed by paper-and-pencil examinations. Even when advanced computer technology is employed to administer the test itself, the prospective physician is primarily asked to display intellectual skills. How to conduct valid, reliable, and cost-effective assessments of clinical and communication skills has been a perennial dilemma for both medical schools and licensing authorities ever since medicine replaced its original apprenticeship system with formal instruction in organized schools.

Patient Instructors in Arizona: A clever solution using what were first called “patient instructors,” but are now known everywhere as “standardized patients,” was invented by Paula L. Stillman, then a pediatrician on the faculty of the University of Arizona. Her idea, piloted with the help of a small grant in 1977 from the private National Fund for Medical Education (NFME), was fully developed and implemented with support from a 1980 FIPSE grant entitled “Patient instructors: a new methodology to assess clinical competence and ensure quality health care.”

Precursors to this idea did exist. During the 1970s, Robert Kretzschmar, an obstetrician/gynecologist at the University of Iowa, had been using volunteer women as live models to train medical students to do breast and pelvic exams. But these women were passive participants, lending their bodies for this purpose but playing no other instructional role.

Editors and publishers take our responsibilities seriously. There are international congresses on peer review in biomedical publications, the most important contributions from which are published in classic, special issues of JAMA. (1-3) A wide range of topics is discussed, including the nature of peer review, whether reviews should be anonymous, whether reviewers should be blinded to the identity of the authors, techniques to minimize publication bias, ways of dealing with plagiarism, the impact of fraudulent research on scientific literature, the effects of institutional prestige and author nationality on reviewers’ recommendations, and many other topics.

While the importance of correcting medical literature after fraudulent publication has been addressed, surprisingly little attention has been paid to the important issue of correcting the medical literature after publication of bad papers. As noted in a previous editorial, (4) the peer-review process is intended to detect poorly designed or misleading articles before they are published. The process is flawed, however; substandard articles can appear in any journal.

Editors try to avoid this unfortunate occurrence in several ways. Usually, we assign submitted manuscripts to more than one reviewer, and we select reviewers who should be knowledgeable about the subject matter being reviewed. Moreover, we encourage our editorial boards to return manuscripts that are outside their areas of expertise and to suggest alternate or supplemental reviewers. For example, it is common for reviewers to request that a manuscript receive additional review by a statistician, to be certain that no sophisticated errors go unrecognized, especially if such errors might affect the validity of the conclusions.

Despite our best efforts, once in a while we publish something that should not have been published. Hence, it is surprising that so little attention has been paid to the obligation of a journal to acknowledge this situation and correct the literature when correction is warranted. This shortcoming is true not only in international symposia, but also in our field.

Otolaryngology journal editors meet twice a year (at COSM and at the AAO-HNS meeting) to discuss a variety of subjects ranging from standardization of terminology to the problem of duplicate publication, but this issue has not been on our agenda. I suspect that most of us have assumed that such corrections are handled adequately through letters to the editor, editorials, or retractions. However, addressing such issues occurs at the discretion of the editor in most cases. So, response to such events varies.

The existence of this problem was brought to my attention recently through my correspondence with the Journal of the American College of Surgeons (JACS), certainly a deservedly well-respected publication. In October, JACS published an article on voice changes after thyroidectomy. (5) While I was delighted to see an article on voice in the College’s journal, I was dismayed at its quality. The clinical examinations were not sufficiently sophisticated to meet the current standards of clinical care, let alone those of clinical research. No blinded, subjective analysis of the clinical data was included. Preoperative and postoperative laryngeal electromyographic data were not provided, so the status of laryngeal nerve function remains unknown. The voice-analysis system used is not particularly sophisticated, and details of recording protocols were not provided. Also, the parameters selected for reporting were inappropriate. The analysis program used generates data on a variety of other measures, but this paper excluded those data and provided no information as to why they were excluded.

More importantly, the errors in the data reported in this article are profound in their naivete. For example, shimmer was described as a measure of intensity. This is completely inaccurate. Shimmer is a perturbation measure that describes cycle-to-cycle amplitude variation and has no predictable correlation with vocal intensity. Intensity should be measured in decibels SPL under carefully controlled conditions.

This article was fatally flawed and would not have been accepted in any otolaryngology journal. Immediately after the article was published, I wrote a letter to Timothy J. Eberlein, MD, editor of JACS, and I received an admirably prompt, standard rejection letter indicating that the rejection “usually reflects issues of timeliness, a backlog, or beliefs that the material, when complete, did not fit our readership.” I would have accepted this outcome happily if my letter had been rejected because another letter had been accepted and was to be published to point out the shortcomings of Sinagra et al’s article. However, follow-up contacts with the journal have indicated that this is not the case. Hence, readers of JACS, most of whom are not sophisticated in their analysis of voice literature, are likely to believe the unsupportable conclusions stated in this article. For otolaryngologists who read other voice literature, this may not be a problem; but for thyroid surgeons who primarily

With the recent passing of former U.S. President Ronald Reagan after a long battle with Alzheimer’s disease, his wife Nancy Reagan joined an unusual coalition of Republicans and Democrats, such has Orrin Hatch and Diane Feinstein, in calling for expanded federal funding for human embryonic stem cell research, including research into cloning human embryos for use and destruction in research. The language used was that of cures, with the implication that not using increased tax dollars to pursue this avenue of research would directly and surely result in the deaths of sick patients.

That call was opposed by another bipartisan coalition, including President Bush, who claimed that the limited federal funding for medical research should not include expanding already existing funding for embryonic stem cell research, but that the amount available now is sufficient, and that allows funding to be directed toward other important areas of research, including therapies that utilize stem cells from patients’ own bodies, drug therapies, and other innovative, non-destructive techniques. This debate will continue in the months and years to come, as traditional partisan alliances morph and the demand for all types of publicly funded medical research grows.

Proponents of expanding the current federal funding for embryo research, including human cloning, speak of “therapeutic cloning,” “somatic cell nuclear transfer” (SCNT), and “unfertilized blastocysts.” But for whom is “therapeutic cloning” actually therapeutic? What does the process involve? And is an “unfertilized blastocyst” really anything other than a human clone?All human cloning, as with animal cloning, is done by the process of somatic cell nuclear transfer. This is nothing more than the process by which the nuclear DNA from a normal, adult body cell is taken and injected into an egg cell which has been enucleated (had its nucleus removed). The newly formed zygote (single-celled embryo) is then given a small electrical shock in order to begin the process of cell division, just as any other embryo would undergo. In fact, it is then indistinguishable from any other embryo. There are no genetic or other markers to indicate, “This is a clone.” This cloned embryo is what proponents of cloning research choose to call an “unfertilized blastocyst.” This is really nothing more than semantic dissembling to give people the idea that the cloned human embryo is somehow other than human, something that can simply be created and destroyed at will for any purpose without any moral issue. The term itself is scientifically incorrect, as the cell’s nuclear DNA was originally the result of a fertilization process, and the cloned embryo must grow to become a blastocyst (14-celled embryo), just as all embryos pass through the blastocyst stage.

Once this cloned embryo has grown and divided for approximately 10 days, it can have its stem cells harvested, a process which inherently involves the destruction of the embryo. This is what is known as “therapeutic cloning.” The process required to gain access to these stem cells, however, is anything but therapeutic for those involved. Cloning is a notoriously inefficient process, with hundreds of attempts required to develop a single, healthy clone. For this, hundreds of eggs are needed, and they must be harvested from women’s bodies. In order for a woman to donate her eggs for this kind of research, she must take the dangerous drug Lupron to stimulate her ovaries to mature many eggs at once, then she must undergo surgery to remove the eggs. All of this is done with no medical benefit whatsoever to her. The cloned embryos are created using these eggs, the vast majority of which do not survive, and those that do almost always have significant health problems that are not initially identifiable.

What should be made of the call for the federal funding of human cloning? Its proponents would use dissembling language to dehumanize the clones so that the public is unaware that they are seeking to use taxpayer money to create thousands of human clones solely for the purpose of destruction in research. All people of conscience want to provide cures for those who suffer with debilitating illnesses, but using the bodies of women as egg factories and creating human clones simply to destroy them is not the way to accomplish that end. There are other very promising avenues of research, including research using adult stem cells, that should receive heightened attention and public funding instead.

The Thai government has launched the Thailand Center of Excellence for Life Sciences Pharmacogenomics Project, in collaboration with Oracle, to gather and unify health records electronically.

The project involves the development of a large-scale database of unified electronic health records and is intended to provide safer and more effective medications as well as reduced health care costs.

Pharmacogenomics defines how a person’s genetics affects his or her body’s response to medications. It is the basis for individualized medicine, through which drugs are tailored and applied to cater to a person’s personal genetic makeup.

Pharmacogenomics could be a leap forward for health care. At the clinical trial level, it involves information sharing, investigator and patient management, and terminology translation.

At the health care level, it involves biomedical surveillance, determining clinical pathways for standardized patient care and gathering patient and physician information into a centralized database.

Who says small community hospitals don’t use cutting edge IT, or that age is a negative factor in healthcare professionals willingness o adopt it? Who says increased efficiency through IT leads to lay-offs, or that speech recognition technology is best suited to American-born doctors?

Brooks Memorial Hospital in Dunkirk, N.Y., is smashing misconceptions left and right with its creative and successful use of EXSpeech from Stratford, Conn.-based Dictaphone Corp. The hospital’s journey down the speech recognition road began several years ago, as it was replacing its text product and was offered a promotional opportunity by Dictaphone that would, in part, reduce its initial investment in speech technology.

Brooks Memorial Director of Medical Records Cheryll Rogers leaped at that one. “Brooks Memorial’s administration is very progressive. Our president has talked for years about speech recognition technology, so when a promotional opportunity made it possible to purchase 10 speech licenses, we thought that would be a great introduction to the technology. At the time, we also thought 10 licenses would be plenty.”

When the time came to select a transcription text product, Brooks Memorial Hospital involved their transcriptionists in a month-long process of examining several vendors’ text products before officially signing on with their selection of Dictaphone’s EX-text. It was a short but intense period of hands-on due diligence. In the end, Transcription Supervisor Sandy Congdon says the hospital chose the Dictaphone product primarily for ease of use, but also for the reassurance of their support system. “Doctors dictate 24/7, so transcriptionists need support 24/7, too,” she says. Those promotional-opportunity benefits to add on the speech recognition product also were an incentive.

Then said they unto him, Say now Shibboleth: and he said Sibboleth: for he could not frame to pronounce it right. Then they took him and slew him, at the passes of Jordan: and there fell at that time of the Ephraimites forty and two thousand.

Judges 12:6

In Old Testament times, mispronunciation bore a price. The Gileadites (circa 1143 B.C.) used pronunciation to differentiate their own from the Ephraimites, and the consequences of mispronunciation were severe. Today, mispronunciation, though not a matter of life and death, presents problems when it interferes with communication. In scientific nomenclature, Greek or Latin bionomials of infectious disease microorganisms are often mispronounced, sometimes causing confusion among healthcare professionals (e.g., infectious disease physicians, epidemiologists, and even microbiologists). Unlike horticulturalists, who have masterfully developed a large repertoire of common names for botanical species thereby avoiding the need for and potential mispronunciation of classical Greek and Latin, infectious disease specialists still rely on Greek and Latin bionomials.

How important is a standard pronunciation of bionomials? Language is about communication. Provided the parties in a discussion can understand each other, variations in pronunciation of individual words can be tolerated or disregarded. Everyday modern English is filled with examples of variant pronunciations that cause no communication problems (e.g., either, tomato, laboratory, fertile). These variant pronunciations have many causes. Regional practice is probably the single most important variant, but educational and social backgrounds also play a part, as do personal preferences and even etymologic theories. It would be futile and (some believe) undesirable to impose uniformity by prescribing approved pronunciations when communication is not compromised. Moreover, in all languages, pronunciation changes constantly.

PhatWare Corp. has released an updated version of Medical Pack, a 130,000-word English language medical dictionary intended to be used with CalliGrapher and PenOffice. The two products, used by physicians to record handwritten notes on Windows-based tablet PCs and handhelds during rounds, have built-in natural handwriting recognition software that provides word suggestions based on the physician’s handwritten notes. When combined with its standard English dictionary, Medical Pack draws on 225,000 total words to help physicians and other medical professionals spell-check medical documents in common applications like Pocket Word and Notepad. It also contains medical abbreviations, prescription drugs and medical terminology.