Inclusion of Recognized Terminologies within EHRs and other Health Information Technology Solutions

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Adopted By: ANA Board of Directors, March 19, 2015

Purpose: The purpose of this position statement is to reaffirm the American Nurses Association’s (ANA) support for the use of recognized terminologies supporting nursing practice as valuable representations of nursing practice and to promote the integration of those terminologies into information technology solutions. Standardized terminologies have become a significant vehicle for facilitating interoperability between different concepts, nomenclatures, and information systems. (ANA, 2015)

Statement of ANA Position: The American Nurses Association continues to advocate for the use of the ANA recognized terminologies supporting nursing practice within the Electronic Health Record (EHR) and other health information technology solutions. Therefore, in alignment with national requirements for standardization of data and information exchange, ANA supports the following recommendations:

  1. All health care settings should create a plan for implementing an ANA recognized terminology supporting nursing practice within their EHR.
  2. Each setting type should achieve consensus on a standard terminology that best suits their needs and select that terminology for their EHR, either individually or collectively as a group (e.g. EHR user group).
  3. Education should be available and guidance developed for selecting the recognized terminology that best suits the needs for a specific setting.
  4. When exchanging a Consolidated Continuity of Care Document (C-CDA) with another setting for problems and care plans, Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT®) and Logical Observation Identifiers Names and Codes (LOINC®) should be used for exchange. LOINC® should be used for coding nursing assessments and outcomes and SNOMED CT® for problems, interventions, and observation findings.
  5. Health information exchange between providers using the same terminology does not require conversion of the data to SNOMED CT® or LOINC® codes.
  6. Development of a clinical data repository that includes multiple recognized terminologies should be based on the national recognized terminologies of ICD-9 (or 10), CPT, RxNorm, SNOMED CT®, and LOINC®. Background: Nursing terminologies identify, define, and code concepts in an organized structure to represent nursing knowledge. Since 1973, multiple organizations have developed nursing terminologies. ANA created a recognition process beginning in 1989 to identify terminologies (aka classification systems) or data sets that support nursing practice and knowledge generation.