SNOMED-CT como modelo de sistema de lenguaje estándar para enfermería: revisión integradora

Silva, Carolina Giordani da; Vega, Edwing Alberto Urrea; Cordova, Fernanda Peixoto; Carneiro, Flávia Aline; Azzolin, Karina de Oliveira; Rosso, Lucas Henrique de; Graeff, Murilo dos Santos; Carvalho, Patrícia Vasconcellos de; Almeida, Miriam de Abreu

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Revista Gaúcha de Enfermagem

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Sumário

Integrative Review • Rev. Gaúcha Enferm. 41 • 2020 • https://doi.org/10.1590/1983-1447.2020.20190281 copiar

SNOMED-CT como modelo de sistema de lenguaje estándar para enfermería: revisión integradora

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

Describir el uso de Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) como modelo de interoperabilidad de las terminologías de enfermería en el contexto nacional e internacional.

Metodología:

Se trata de revisión integradora de la literatura según Cooper, que buscó estudios en portugués, inglés y español, publicados entre septiembre de 2011 y noviembre de 2018 en las bases de datos BVS, PubMed, SCOPUS, CINAHL, EMBASE y Web of Science, que culminó en una muestra de 15 artículos.

Resultados:

SNOMED-CT es una nomenclatura multiprofesional empleada por la enfermería en diferentes contextos de cuidado, asociado a otros lenguajes estandarizados de enfermería como CIPE^®, NANDA-I y Omaha System.

Conclusión:

Esta revisión demostró que el uso de SNOMED-CT es incipiente en el contexto nacional, lo que justifica la necesidad de desarrollar estudios destinados a mapear los sistemas de lenguajes estandarizados existentes, especialmente NANDA-I, CIPE y Omaha System, con el propósito de adaptar la implementación de SNOMED-CT.

Palabras clave
Informática aplicada a la enfermería; Terminología normalizada de enfermería; Systematized Nomenclature of Medicine; Clasificación; Interoperabilidad de la información en salud

Title/Author(s)	Country/Year/Journal	Objective	Type of study/Level of Evidence
A Shovel-Ready Solution to Fill the Nursing Data Gap in the Interdisciplinary Clinical Picture. Keenan et. al1818. Keenan GM, Lopez KD, Sousa VEC, Stifter J, Macieira TGR, Boyd AD, et al. A shovel-ready solution to fill the nursing data gap in the interdisciplinary clinical picture. Int J Nurs Knowl. 2018 Jan;29(1):49-58. doi: http://doi.wiley.com/10.1111/2047-3095.12168 http://doi.wiley.com/10.1111/2047-3095.1...	USA, 2018 International Journal of Nursing Knowledge	To critically evaluate 2014 American Academy of Nursing (AAN) call-to-action plan for generating interoperable nursing data.	Exploratory / Level 4
Re-use of SNOMED-CT subset in development of the Danish national standard for home care nursing problems. Højen, Gøeg, Elberg1919. Højen AR, Gøeg KR, Elberg PB. Re-use of SNOMED-CT subset in development of the Danish national standard for home care nursing problems. Stud Health Technol Inform. 2015;210:140-4. https://doi.org/10.3233/978-1-61499-512-8-140 https://doi.org/10.3233/978-1-61499-512-...	Denmark, 2015 Studies in Health Technology and Informatics	To present the four step approach to utilize existing SNOMED CT subsets for development of subsets that suite a specific clinical use case.	Cross-mapping / Level 4
Standardizing Physiologic Assessment Data to Enable Big Data Analytics. Matney et al2020. Matney SA, Settergren T, Carrington JM, Richesson RL, Sheide A, Westra BL. Standardizing physiologic assessment data to enable big data analytics. West J Nurs Res. 2017 Jan;39(1):63-77. doi: https://doi.org/10.1177/0193945916659471 https://doi.org/10.1177/0193945916659471...	USA, 2017 Western Journal of Nursing Research	To align a minimum set of physiological nursing assessment data elements with national standardized coding systems.	Cross-mapping / Level 4
Automating lexical cross mapping of the International Classification for the Nursing Practice (ICNP) to SNOMED-CT. Kim2121. Kim TY. Automating lexical cross-mapping of ICNP to SNOMED CT. Informatics Heal Soc Care. 2016 Jan;41(1):64-77. doi: https://doi.org/10.3109/17538157.2014.948173 https://doi.org/10.3109/17538157.2014.94...	England, 2016 Informatics for Health & Social Care	To examine the feasibility of automating the lexical cross-mapping of a logic-based nursing terminology (ICNP^®) for SNOMED-CT using the Unified Medical Language System (UMLS) maintained by the National Library of Medicine.	Cross-mapping / Level 4
Mapping evidence-based guidelines to standardized nursing terminologies. Dontje & Coenen2222. Dontje K, Coenen A. Mapping evidence-based guidelines to standardized nursing terminologies. Comput Inform Nurs. 2011 Dec;29(12):698-705. doi: https://doi.org/10.1097/NCN.0b013e31822b84e6 https://doi.org/10.1097/NCN.0b013e31822b...	USA, 2011 CIN: Computers, Informatics, Nursing	To describe the use of standardized nursing terminologies to represent evidence-based practice recommendations for patients with depression in primary care.	Concept analysis / Level 4
SNOMED-CT implementation: implications of choosing clinical findings or observable entities. Rasmussen, Rosenbeck2323. Rasmussen AR, Rosenbeck K. SNOMED CT implementation: implications of choosing clinical findings or observable entities. Stud Health Technol Inform. 2011;169:809-13. doi: https://doi.org/10.3233/978-1-60750-806-9-809 https://doi.org/10.3233/978-1-60750-806-...	Denmark, 2011 Studies in Health Technology and Informatics	To analyse SNOMED CT implementation in an Electronic Health Record (EHR).	Cross-mapping / Level 4
Mapping perinatal nursing process measurement concepts to standard terminologies. Ivory2424. Ivory CH. Mapping perinatal nursing process measurement concepts to standard terminologies. Comput Inform Nurs. 2016 Jul;34(7):312-20. doi: https://doi.org/10.1097/CIN.0000000000000243 https://doi.org/10.1097/CIN.000000000000...	USA, 2016 CIN: Computers, Informatics, Nursing	To determine which Perinatal Failure to Rescue (P-FTR) data elements were present in selected American Nurses Association (ANA) recognized standard terminologies.	Cross-mapping / Level 4
Communicating nursing care using the health level seven consolidated clinical document architecture release 2 care plan. Matney, Dolin, Buhl, Sheide2525. Matney SA, Dolin G, Buhl L, Sheide A. Communicating nursing care using the health level seven consolidated clinical document architecture release 2 care plan. Comput Inform Nurs. 2016 Mar;34(3):128-36. doi: https://doi.org/10.1097/CIN.0000000000000214 https://doi.org/10.1097/CIN.000000000000...	USA, 2016 CIN: Computers, Informatics, Nursing	To describe the Consolidated Clinical Document Architecture (C-CDA), introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan.	Description / Level 4
Mapping wound assessment data elements in SNOMED-CT. Block, Handfield2626. Block L, Handfield S. Mapping wound assessment data elements in SNOMED CT. Stud Health Technol Inform. 2016;225:1078-9. doi: https://doi.org/10.3233/978-1-61499-658-3-1078 https://doi.org/10.3233/978-1-61499-658-...	Canada, 2016 Nursing Informatics	To present the mapping activity of wound assessment data elements to SNOMED-CT.	Cross-mapping / Level 4
Development of the nursing problem list subset of SNOMED-CT. Matney, Warren, Evans, Kim, Coenen2727. Matney SA, Warren JJ, Evans JL, Kim TY, Coenen A, Auld VA. Development of the nursing problem list subset of SNOMED CT®. J Biomed Inform. 2012 Aug;45(4):683-8. doi: https://doi.org/10.1016/j.jbi.2011.12.003 https://doi.org/10.1016/j.jbi.2011.12.00...	USA, 2012 Journal of Biomedical Informatics	To create an interoperable set of ND for use in the patient's problem list in the Electronic Health Records (EHR) to support interoperability.	Cross-mapping / Level 4
Interterminology mapping of nursing problems. Kim, Hardiker, Coenen2828. Kim TY, Hardiker N, Coenen A. Inter-terminology mapping of nursing problems. J Biomed Inform. 2014 Jun;49:213-20. doi: https://doi.org/10.1016/j.jbi.2014.03.001 https://doi.org/10.1016/j.jbi.2014.03.00...	USA, 2014 Journal of Biomedical Informatics	To determine the degree of overlap between ICNP^® and SNOMED-CT, with a focus on nursing problems, as a first step towards harmonization between the two terminologies.	Cross-mapping / Level 4
Rigor in electronic health record knowledge representation: Lessons learned from a SNOMED-CT clinical content encoding exercise. Monsen, Finn, Fleming, Garner, LaValla2929. Monsen KA, Finn RS, Fleming TE, Garner EJ, Lavalla AJ, Riemer JG. Rigor in electronic health record knowledge representation: lessons learned from a SNOMED CT clinical content encoding exercise. Informatics Heal Soc Care. 2014 Oct;41(2):1-15. doi: https://doi.org/10.3109/17538157.2014.965302 https://doi.org/10.3109/17538157.2014.96...	USA, 2014 Informatics for Health & Social Care	To educate clinicians and students about knowledge representation and to evaluate their success of applying the manual lookups method for assigning Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) concept identifiers using formally mapped concepts from the Omaha System interface terminology.	Cross-mapping / Level 4
Toward Improving Quality of End-of-Life Care: Encoding Clinical Guidelines and Standing Orders Using the Omaha System. Slipka, Monsen3030. Slipka AF, Monsen KA. Toward improving quality of end-of-life care: encoding clinical guidelines and standing orders using the Omaha System. Worldviews Evid Based Nurs. 2018 Feb;15(1):26-37. doi: https://doi.org/10.1111/wvn.12248 https://doi.org/10.1111/wvn.12248...	USA, 2018 Worldviews on Evidence Based Nursing	To investigate the feasibility of using the Omaha System as a framework for encoding interoperable evidence-based EOL interventions with specified temporality for use across disciplines and settings.	Retrospective study / Level 4
Harmonising ICNP and SNOMED-CT: A model for effective collaboration. Hardiker3131. Hardiker N. Harmonising ICNP and SNOMED-CT: a model for effective collaboration. Studies in health technology and informatics. 2016 Jan;225:744-5. doi: https://doi.org/10.3233/978-1-61499-658-3-744 https://doi.org/10.3233/978-1-61499-658-...	United Kingdom, 2016 Nursing Informatics	To demonstrate an approach to collaborative working within nursing and health informatics.	Experience report / Level 5
Semantic mappings and locality of nursing diagnostic concepts in UMLS. Kim, Coenen, Hardiker3232. Kim TY, Coenen A, Hardiker N. Semantic mappings and locality of nursing diagnostic concepts in UMLS. J Biomed Inform. 2012 Feb;45(1):93-100. doi: https://doi.org/10.1016/j.jbi.2011.09.002 https://doi.org/10.1016/j.jbi.2011.09.00...	USA, 2012 Journal of Biomedical Informatics	To determine the concordance of semantic mappings of the selected diagnostic concepts in the unified framework; to exploit synonymous relationships of diagnostic concepts across the source terminologies; and to explore the placement of the selected nursing concepts on the UMLS Semantic Network.	Cross-mapping / Level 4

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[1] Corresponding author:
Carolina Giordani da Silva E-mail: carol.giordani@gmail.com