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Learning Objective 1: Discuss the state of the science and the use of standardized nursing terminologies (SNTs) to advance decision support through clinical information systems (CIS).
Learning Objective 2: Apply an exemplar from research using SNT to link evidence-based practice recommendations for depression in primary care to decision support systems in the CIS.
Standardized nursing terminologies (SNT) were developed to provide a standard means for nurses to document the domain of nursing practice, integrate nursing concepts into CIS, and improve ease of data use and retrieval. Evidence-based practice (EBP) recommendations provide guidelines for best nursing practice. CDS systems provide information and knowledge to nurses at the point of care. Conceptual frameworks representing the relationships among these tools (SNTs, EBP recommendations, and CDS systems) will be examined in this paper. The ability to use these tools to measure patient outcomes for national and international comparison also will be discussed.
An exemplar describing the development of EBP recommendations and mapping these recommendations to SNTs will be presented. EBP recommendations for adult patients with depression in primary care were decomposed into 118 key concepts; these key concepts were mapped to two SNTs (Omaha System and International Classification for Nursing Practice). Results included that 93% of the EBP recommendation key concepts were able to be mapped to one or both of the SNTs. The majority (83%) of these were partial semantic (conceptual) matches, with only 10% complete matches. This research begins to examine the use of SNTs to represent EBP recommendations to support linkages to clinical data in CIS for CDS. Further research is needed to examine the use of SNTs to reduce ambiguity of concepts and support the development of CDS applications within the CIS.