5. Exchange Data with Internal and External Systems

Health care agencies seldom have the luxury of a single, monolithic automated system. It is far more common that an agency will have multiple computers using different software platforms to accommodate their information processing requirements for clinical systems, administrative systems, financial systems, research systems, etc. When clinical data are needed by other systems, it must be possible to supply that data without re-entering it. Standards for packaging data and transporting them to "foreign" systems are evolving; to the extent that a nomenclature is structured to conform to those standards, then exchanging data will be made easier (Board of Directors of the American Medical Informatics Association, 1994).

A major effort is underway to develop a clinical nursing classification scheme expressly for use in automated systems. The International Council of Nurses sponsors development of the International Classification of Nursing Practice (ICNP) (International Council of Nurses, 1996; Neilson & Mortensen, 1996). Still in its early phases, the nomenclature is intended to provide a common language for describing all of nursing practice across all settings and geographic locations. It includes a framework for mapping to existing nomenclatures and classifications. The developers encourage feedback and suggestions for additions and changes funneled through the American Nurses Association (Warren & Coenen, 1998).

Table 1.
Functions	Characteristics
Provide the legal record of care	Domain completeness, synonymy, granularity, modifiers, non-ambiguity, multi-axial, combinatorial, parsimony, syntax and grammar, clinical utility
Support clinical decision making	Granularity, unique and context-free identifiers, hierarchical organization with multiple parents possible, clarity, non-redundancy, term definitions
Capture costs for billing/costing/accounting	Able to be mapped to administrative classifications
Accumulate structured database for administrative queries, quality assurance, research	Terms with unique identifiers, clarity, non-redundancy, term definitions, domain completeness, granularity, hierarchical organization
Support data exchange with internal and external systems	Conform to data exchange standards

The characteristics of a "good" nursing nomenclature from an informatics perspective are summarized in Table 1. Most of them have been listed by others as required attributes in any classification scheme that will be implemented in a computer-based patient record (Campbell, Carpenter, Sneiderman, Cohn et al, 1997; Henry, Warren, Lang & Button, 1998). Much of that work has foundations in the work of the Canon group, a gathering of researchers whose aim was to synthesize existing efforts at medical concept representation (Evans & Cimino, 1994).

The topic has taken on more urgency in the past few years because of frustration with the slow pace of implementation of automated systems to support clinical care (United States General Accounting Office, 1993), and because of federal initiatives such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that will require standards for coding and transmitting claims and other medical record data. The work of the nomenclature developers who are cited here, as well as the work of informaticians who examine, compare and evaluate existing nomenclatures for applicability in automated systems, is absolutely fundamental to achieving automated clinical systems that support both efficiency and effectiveness of care.