Figure 1, above, [click here for larger version] depicts a framework that provides conceptual insight into vocabulary needs for policy and management practice decision-making in healthcare. This model builds on Eisenberg's (1998) discussion of healthcare as occurring at the levels of society, health systems, and clinical practice. Similarly, management decision-making occurs at the levels of population, group, and individual. For example, clinical management decisions focus on case and care management: at the individual level through assessment, planning, implementation, and evaluation of an individual's plan of care; at the group level as coordination and facilitation of care across a group of patients with similar care needs; and at the population level as integration of care across aggregates of similar and different groups with common health care needs, most notably morbidity, mortality, health promotion and disease prevention. This figure denotes the reciprocal relationship between management and policy decision-making, and the incorporation of vocabulary at all levels of decision-making.

This model assumes that there are three types of vocabularies needed in health care. The point of care is an "interface" vocabulary that occurs at the individual and practice level, and includes terms that are used between clinician and patient, and/or clinician and clinician to describe and convey related patient and clinical information. Vocabularies at the point of service level emphasize the settings where care is delivered, and are often discipline or specialty focused. Obviously, different vocabularies and classifications are needed to represent point of care vocabulary in nursing across the continuum of care (e.g., prevention to primary care to sub-acute care, to acute care, etc.). Examples of existing information systems that provide interface vocabulary to support decision-making at the patient care level are Oceania (http://www.oceania.com) and a Canadian information system called Purkinje (http://www.purkinje.com).

Network is represented by terms and phrases that serve as a "reference" vocabulary to link clinicians' documentation across horizontally or vertically integrated systems of care delivery (e.g., a hospital system or primary care clinic system, and health maintenance organization, respectively). Reference vocabularies are based on knowledge derived through interface, and reflect an integration and classification of knowledge. Thus, the individual practice encounter is used to build information and knowledge for decision-making at a group or network level. Vocabularies at this higher level of abstraction synthesize knowledge from multiple settings, disciplines and specialties interacting at the point of care, integrate and classify that knowledge, and build information and knowledge for decision-making to link group and system decisions.

Table 2.

Rationale for use of a reference health care vocabulary in measuring quality, outcomes,and evidence research in nursing

Provides the link between health care knowledge found in the literature and inquiring health professionals who need to keep up with the literature Facilitates examination of community nursing practice which requires uniformity of clinical data and concepts, or accurate mapping of vocabulary terms that have the same meaning or refer to the same concept Enables the evaluation of practice innovation impacts, such as practice guidelines, evidence, and other nursing knowledge, on the practitioner closest to the point of patient care, who requires a vocabulary infrastructure that is consistent with financial, administrative, and clinical databases Provides the ability to conduct research on patient outcomes by linking patient records and patient outcome data to examine the impact of patient conditions and clinical treatments on patients' health status, return-to-work, quality of life, and other outcomes. Facilitates the integration of new development tools used by purchasers and producers of health care with clinical, financial, and administrative vocabularies to fully examine quality in health care

There are currently no existing systems at the network level that link all health professional vocabularies within systems or groups of providers. However, this level of vocabulary is essential to measuring and monitoring quality, examining health outcomes, determining effectiveness of health care delivery, and developing an evidence base for practice. Table 2 provides further rationale for the network level of vocabulary. SNOMED International (Systematized Nomenclature of Human and Veterinary Medicine) is a complex but comprehensive classification system for "indexing the entire medical record, including signs and symptoms, diagnoses, and procedures. Its unique design will allow full integration of all medical information in the electronic medical record into a single data structure." (http://snomed.org). SNOMED is investing money to develop a reference or network level health care vocabulary for the United States. Other U.S. vocabularies that are considered beginning network vocabularies are MEDCIN, MEDICOMP, and Dr. Elmer Gabrieli's natural language processing (Gabrieli, 1993).

Universal or "administrative" vocabulary is the highest level of vocabulary, and links information on populations of people in a community, state, country, or globally (e.g., ICD- 9 or -10 coding system from the World Health Organization, or an International Classification of Nursing Practice (ICNP)). Universal vocabularies build on knowledge and information obtained at the point of service and network levels, and reflect the highest level of integration and synthesis of knowledge, and a combination of vocabularies for societal and population decision-making. For example, population statistics from a community, state or country are synthesized and analyzed to identify health care needs, and the numbers of people who die from certain disease conditions. At the international level the World Health Organization can determine the major conditions causing mortality within different countries by age groups and across the world. Universal vocabulary currently guiding decisions in global health care is the International Classification of Diseases (ICD) Versions 9 and 10 (CM is the Clinical Modification used in the U.S.). The ICD does not completely integrate population and society data, but reflects primarily medical diagnoses and phenomena. The ICD-9-CM is the classification used by the Health Care Financing Administration (HCFA) to reimburse for care delivered to Medicare and Medicaid recipients in the United States.