1. Nursing Occupations Proposed by: Cynthia Lundberg, BSN Judith Warren, PhD, RN

2. Nursing Occupations Project  The problem of EHRs not having a standardized terminology that contains distinct, unambiguous, understandable, and useful nurse professional occupations/roles will impact querying.  Lack of specifics will impair research analysis for improving patient safety, quality of care, and cost effectiveness.  For example, nursing occupations support research of nursing staff levels required based upon patient acuity.  These types of reports can also be used to identify if an inappropriate level of staff contributed to a medical or medication error and identify appropriate levels of nurse needed to improve quality patient care.

3. Nursing Occupations Project  The requirement of having the ability to query for professional roles/credentials at the “Is_A” relationship level is essential when assessing if the appropriate level of nursing occupation was performing patient care and how this role affected the quality of patient care.  The need for unambiguous nurse occupation/roles is necessary to post-coordinate ”referral to (observable entity) CID 440379008” and ” referral by (observable entity) CID 440377005” with the appropriate nurse role.

4. Risks  Inability to reach consensus of nursing occupations/roles for the Core and the country extensions  The priority given to the work to will be so low as to require years before the content is fixed  Some countries have yet to develop extensions and so the content may be lost

5. Process for Conducting the Project  The hierarchies will be searched for all nursing occupations/roles  Proposal made for correct placement  SNOMED code result set will be saved as a value set.  The Nursing SIG will validate the SNOMED CT Nursing Occupations/role revision proposal  Revisions made as necessary and then submitted to the Nursing SIG

6. Beneficiaries  Patient  When the role of the nurse is specified, then resources can be understood and allocated to patient care.  Nurse caring for the patient:  Knowing the nursing occupation/role will facilitate identification of of the impact of care on patient outcomes;  Knowing what nurses do in their roles  Researcher:  Nursing occupation/role data will be consistent and measurable across multiple enterprises.

7. Risks  Inability of the incoming SNOMED CT code to be translated in receiving system.  Incoming applications will need a translation methodology for translating the SNOMED CT code to the nursing terminology they use.  There will need to be a process for handling SNOMED CT codes that do not translate into the terminology used in the receiving care setting  SNOMED CT Nursing Problem List set will become out of synch with corresponding nursing terminologies when they release new versions.  To mitigate this risk the Nursing SIG will communicate with the developers to gain their collaboration.

8. Results  Nurse role/occupations are a subtype of the Social Context hierarchy  SNOMED CT contained 147 nurse role/occupation concepts  The only defining concepts is the Is_A defining relationship.  There are no other defining attributes that have been approved by the IHTSDO which means that the occupations cannot be fully defined today.  Of the 147 total role/occupation concepts 129 concepts have been defined unambiguously, are expressed with a FSN, and have been defined correctly in the Is_A defining relationship.

9. Results  129 concepts are international in scope and are recommended to remain within SNOMED CT core.  1 concept is being recommended to be submitted as a new IHTSDO request.  “Chief nursing officer “ is being requested so that nursing officer concepts can be classified under it.  For example, nursing officer (occupation) CID 158990003 Is_A Chief nursing officer  10 are being proposed to be moved from SNOMED CT core to an extension file as these concepts have been found to be country specific.

10. Role/Occupation Concepts Proposed to be Moved to a Country’s Extension File  SNOMED CT FSNCID Country Extension  Integrated midwife 312485001 United Kingdom / Philippines  Foot care worker 22460300 United Kingdom  Professional initiating surgical case 405684005 United Kingdom  Healthcare service manager 224579007 United Kingdom  Nursing officer – district 158985001 United Kingdom  Nursing officer – division 158987009 United Kingdom  Nursing officer - region 158984002 United Kingdom  Nursing sister 224572003 United Kingdom  Registered nurse First Assist 372102007 United Kingdom  Accident and Emergency nurse 224537001 United Kingdom

11. Role/Occupations Being Proposed to be Retired  SNOMED CT FSNCID  Professional providing staff relief during surgical procedure 405685006  Sanitarian45956004  Occupational health service manager224580005  Occupational health nursing officer158989007  Midwifery personnel106294002  Nursing aid73265009  Other professional nurse83189004  Theatre nurse 224561008 

12. Results  Four SNOMED CT concepts have not been defined appropriately using the Is_A defining relationship  The concepts identified as having the inappropriate Is_A have been recommended to be classified under alternate active SNOMED CT concepts within the Social Context hierarchy so that their definitions are disambiguated. Concepts that have been defined with an inappropriate Is_A

13. Newly Proposed Is_A Relationships  SNOMED CT FSN CIDNew Is_A FSNCID  Anesthetic nurse 309445003 Perioperative nurse 415075003  Health visitor 159000000 Professional nurse 106292003  Staff midwife 158995008 Staff nurse 158994007  Registered midwife 309453006 Health visitor/nurse/midwife 309452001

14. Quality Measures Achieved  Number of concepts reviewed=147  What are the current location(s) of nursing occupations/roles concepts in SNOMED CT?  Social Context Hierarchy  Which hierarchy should contain the nursing occupations/roles concepts?  Social Context hierarchy  Number of nursing occupations/roles concepts located accurately =129

15. Quality Measures Achieved  Number of nursing occupations/roles concepts needing to be moved=0  Number of concepts to be retired=8  Number of the nursing occupations/roles concepts belonging in the SNOMED CT Core? 129  Which ones need to be moved to country extensions? =10  Number of the nursing occupations/roles concepts fully modeled according to the style guide=129  What are the obvious missing nursing occupations/roles concepts=1  Number interactions with Nursing SIG participants  One conference call in 2010, Fall 2010

16. Proposed Quality Measures Not Achieved  The following measures were found to be beyond the scope of the project  While logically they were measures, as the project evolved, new understanding occurred  What attributes should the nursing occupations/roles concepts have for URU modeling and clarity of use?  How should they be disambiguated?

17. Issues from Quality Committee  Look at ref set work; is this where we need to go  What about legacy data; should we keep the UK roles in core because when they are moved to an extension, the extension is n ot mentioned so people don’t know where to look  Are the criteria we used to make the recommendation to move to extension, the reverse of what we need to do to determine if they belong in core

18. Questions/Discussion