Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Electronic Health Records…Meaningful Use…Required Patient Care Documentation…Nursing Terminology!


These are among the hot topics of the day in hospitals facing astronomical changes in the technology growth that has affected all aspects of budget, planning, regulation and patient care! These critical issues that are important to nursing warrant rapid dialogue among informed readers, and traditional modes of publishing, like software procurement and implementation, cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook now offers an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession.

In the field of Nursing Informatics, there is no one more well known than Dr. Virginia K. Saba, EdD, RN, FAAN, FACMI, President and CEO SabaCare, who received the FIRST Friends of the National Library of Medicine (FNLM) Nursing Informatics Award for her pioneering work that has rocketed the field of Nursing Informatics nationally and internationally. She gave her remarks at the event on September 14, 2014, in Washington DC. Her publications and manuals are used by many vendors and nurse informaticians to code nursing care. Her comments and opinions are always provocative and she has been instrumental to move the dialogue forward for a nursing terminology that captures the “essence” of nursing electronically, lest our professional actions continue to remain invisible in the electronic health record. Click here to read her comments: Saba FNLM-NI Award Speech Sep 14.

For links to the SABACARE website, click here: SABACARE.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN



Virginia K. Saba, EdD, RN, FAAN FACMI

President and CEO, Sabacare



Click on the bars below to listen to each question in the interview.


Question 1. Why is nursing care not visible in the Electronic Health Record (EHR) or Healthcare Information Technology (HIT) systems which are required for the implementation of the HITECH Act of 2009 and primarily for its ‘meaningful use’ legislative requirements?

Today, professional nursing practice is not visible in the electronic health record (EHR) systems primarily because nursing services are not required to be reimbursable.  The HITECH act of 2009, which implemented “meaningful use,” has not included nursing practice in most of its legislative requirements for Stage 1, which was implemented in 2011/2012 and Stage 2, which started in 2013 and is still going on in 2014. They do not specify nursing involvement related to CPOE (which stands for Computerized Provider Order Entry), Quality Indicators, Outcome Measures, or Discharge Summaries.

At this time, the federal agencies responsible for implementing the “meaningful use initiatives” – namely the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) – do not seem to recognize professional nursing as an essential, independent discipline.  They only seem to recognize those healthcare specialties that are revenue generating because they have established cost values for their coded terminologies that are reimbursable such as the services provided by the laboratory, radiology, pharmacy etc.   However, our professional nursing organizations do not seem to be recommending that nursing departments in hospitals and other healthcare facilities become revenue generating in order to establish costing values for coded nursing services based on a standardized nursing terminology.

The introduction of computers in the patient care setting during the 1970s provided an unprecedented ability both to capture and automatically aggregate nursing care data. Since then, nursing informatics (NI) programs have expanded in our colleges and universities, and the cadre of nursing informatics (NI) certified Experts have emerged.  In 1992, the American Nurses Association (ANA) officially recognized Nursing Informatics as a new nursing specialty. Despite this evidence of successful assimilation of computers by our nursing profession, nursing currently is still invisibile as a member of the healthcare team in the electronic health record (EHR).

The physician-centric focus of the federal requirements for “meaningful use” keeps nursing invisible and puts the needs of nursing in a secondary position.  Currently, nursing departments, as I said, are not revenue generating and do not require [charge] for individual nursing services but remain in the hospital room rate.  Hospitals receive their funding for their nursing staff based on a formula (pre-determined by CMS) that calculates the percentage of the rate per patient for nursing services regardless of the intensity of nursing care required.

Thus the federal government’s incentive program for “meaningful use” provides financial incentives for only physicians and hospitals to implement and utilize electronic health records systems; however, it is virtually ignoring Nursing – and our profession bears much of the responsibility.

Question 2: What is the status of nursing languages in today?  And, are they being used for documenting professional nursing practice?

The American Nurses Association (ANA) has traditionally supported the documentation of nursing practice.  As early as 1970, the ANA recommended that professional nursing documentation should follow the 6 steps of the nursing process.  Since then, the ANA has supported many initiatives and endorsed the integration of computer technology for documenting nursing practice including the development of the criteria for a nursing classification and/or terminology.  In 1992, the ANA recognized the first four of the 12 recognized nursing classifications or terminologies “recognized” today. The twelve languages consist of two data sets, two nomenclatures, and eight classification systems, all of which were developed at different times, by different groups at universities or at private organizations, were structured and classified differently, and are marketed differently.  Also because of the copyright restrictions and how they are structured, the remaining eight classifications cannot be harmonized and even have difficulty being computerized.

Regardless, the ANA does not want to endorse one single free standardized nursing language for the documentation of nursing practice.  As a result, the federal government and the electronic health record system developers or vendors have been presented with the dilemma as to which nursing terminology to endorse, select, and/or recommend.   Because of the different terminology standards review processes the ANA was not able to harmonize or recommend one terminology for the EHR systems.

Furthermore, since several of the nursing terminologies were integrated into the SNOMED-CT, (which stands for Systematized Nomenclature of Medicine -Clinical Terms), the federal government indicated that the nursing terms and concepts in SNOMED CT would be acceptable as a nursing language.  The federal government therefore has designated SNOMED-CT as the ‘interoperable’ standard for electronic healthcare information exchange including nursing which has to map to it to meet federal regulations.

SNOMED- CT was originally developed by the College of American Pathologists (CAP) and distributed in the United States by the National Library of Medicine (NLM) Unified Medical Language System (UMLS) called Metathesaurus.  SNOMED CT is considered to be a reference terminology in that it is similar to a dictionary of thousands of healthcare terms not categorized by specialty but by domains or characteristics. As a result, the nursing terms in SNOMED CT overlap, are not defined, and not easily retrieved for the documenting nursing practice or developing nursing plans of care, making it difficult for nursing to implement in any electronic health record.

Even though nurses represent the largest group of healthcare professionals in hospitals and other healthcare facilities, the nursing profession has not implemented or utilized computers for the documentation of their practice in most hospitals and other healthcare facilities. Furthermore, even though the ANA has outlined professional nursing practice as the documentation of the 6 steps of the nursing process they do not use it to document in actual practice either manually or in any electronic health record (EHR) system. As a result, we have a problem in today’s electronic health record with a mixture of electronic nursing notes that still remain.

Question 3:  Is there a standardized nursing language that can be used for documenting nursing practices? If so what should its characteristics be and why should it be used?

Nursing does have a single nursing language that is free, coded, and has a standardized framework with nursing diagnoses, nursing interventions and nursing outcomes for describing the “essence of nursing care.” It is a unified nursing language with a framework that addresses the 6 steps of the nursing process – namely the Clinical Care Classification (CCC) System.

The CCC System as it is called was empirically developed from research using live patient care data from over 8,000 patients’ documentation for an entire episode of illness.  It consists of two interrelated nursing terminologies: 176 CCCs of Nursing Diagnoses and 528 Outcomes; and 804 CCCs of Nursing Interventions and Actions, both of which are classified by 21 Care Components to for one unified system.  The CCC System is a standardized coded nursing language that has been ‘recognized’ not only by the ANA but also accepted and recognized by the federal government in 2007/8 as a free nursing language that codes “Nursing Care” and has the capability to be exchanged since it is interoperable across settings and systems.                 

The CCC System was specifically designed and developed for the electronic health record (EHR) and requires no licensing fee. It meets all the criteria not only for the ANA but also those recommended by the national standards organizations such as:  the concepts are atomic-level, with a unique identifier that is a code number, explicit definition, has concept permanence (that means they are only used once), and compositionality of the concepts which can combine to form unique concepts etc.  It used a five digit code similar to the coding structure of ICD-10.

The CCC system is used to document nursing practice based on the Nursing Process: assessment, diagnoses, expected outcomes, planned interventions, implementation of the interventions, and evaluation of the patient’s response to the nursing care provided; and also provides unique codes designed to capture all nursing care documentation or nursing plans of care data elements.

Because a single codified nursing language is not being used, our profession has not been able to collect comparable data on nursing practice to demonstrate our value; and, as a result, nursing is being overlooked in the current federal EHR meaningful use initiatives. Instead, vendors are primarily focusing on developing capabilities for physician-centric electronic health record systems that ignore the needs of nurses and that may prevent professional [bedside] nurses from practicing as the independent professionals we’ve struggled so long to become.

If the CCC System was recommended as the primary standardized, coded nursing terminology for documenting nursing practice in the electronic health record, nursing would become “visible.”  The CCC nursing data will be used to measure quality, patient outcomes, workload, as well as the costing out of nursing care.  Such data can also be aggregated to generate evidence from across the continuum of care, showing the positive impact nurses have on patient care. Once a single nursing language is implemented in all EHRs, nursing will be able to communicate effectively and efficiently within and across settings, collect comparable data on nursing practice, become visible, and ultimately provide the federal agencies and healthcare reimbursement entities the patient care data that they need to measure nursing’s unique contribution to patient outcomes.

Nurses must realize the importance of the patient care data they document in providing evidence of the impact nursing care activities have on patient outcomes.

Nursing to embrace the electronic documentation of patient care data is needed in order to prove that what nurses do makes a difference in patient outcomes and to become an independent, visible profession for the practicing nurses.

FOLLOW-UP QUESTION: What is your solution?

My solution is the following: For over 30 years, I have promoted the integration of computer into nursing practice for the benefit of our patients and our profession. Today, we are at the crossroad and can no longer wait for a miracle to happen.  My call to action is for the professional nurses and the professional nursing organizations to demand that the electronic health record systems support coded nursing care data using one unified language that  can be used to document nursing practice based on the ANA’s Nursing Process – namely the CCC System.

That is why I recommend that the CCC system become the nursing profession basic standardized coded language of choice using its framework for collecting the critical data needed to make nursing a visible member of the electronic health care team in the electronic health care systems. This is a critical time for nurses to act! We must become visible to remain viable as a profession.