The authors evaluate the depth of usage of SNOMED CT terms and diagnosis and problem lists with a computerized physician order entry (CPOE) system. The authors states that the methods of combining clinical terminologies and EHR to clearly define medical language are challenging. In order to acquire the benefits of clinical terminologies, researchers have been developing a standardized terminology system, which efficiency supports the process of documenting patients’ information and indexing. Standardized terminology is the key to implement the computer-based clinical decision assistance, retrieving, and aggregation of data. However, creating and maintaining the clinical terminology require a significant resources and this may propose a problem …show more content…
The second method gives providers the ability to type diagnoses, then the SNOMED CT database will search and return with lists of terms related to the typed diagnoses, which allow providers to select the most appropriate one. If the specific term could not be found in the search database, the providers should choose the synonym term and submit the desired term to SNOMED CT administration team, who will investigate and add the absent terms to database. The article shows the result of four-month study period. 56 percent of diagnoses and problems were selected through drop-down lists. 40 percent of diagnoses and problems were chosen from type-text search. Of the 15.11 percent of unique display forms chosen, 11.6 percent of terms were added by administrative team because they were missing from the database. The authors conclude that there is tremendous potential in improving quality of patients’ care by using COPE and SNOMED CT. The computerized diagnoses and problems list is always available and easily accessible, which has a significant role in supporting clinical decisions and generating appropriate code associated with the …show more content…
With the usage of EHR, the process of documentation has been much easier. However, information between different EHR systems is not exchangeable due to lacking of compatibility of those systems. Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) has solved that problem. SNOMED CT is the global clinical terminology that allows patients’ data to be recorded in EHR effectively and meaningfully. SNOMED CT enables different EHR systems to communicate and understand each other. SNOMED CT gives providers and EHR the power to use a common language, which provides consistent and standardized terminologies, allows them to interact with others. SNOMED CT has been assisting in increasing quality of patients’ care across different provider specialties and healthcare organizations. SNOMED CT covers broad ranges of terminologies that are needed to describe patients’ diagnoses and problems. SNOMED CT is structured in multiple subtype hierarchy, which allows information to be recorded precisely in different levels of detail. Therefore, providers from different specialties and disciplines can properly record data at different stages in processes of patients’ care (Ware,
Generally, the development and adoption of Clinical Decision Support (CDS) systems is based on the necessity and essence of technical standards in enhancing healthcare. However, the various health IT tools must comply with some data interchange standards in order to enhance access to clinical records, lessen clinical errors and risks to patient safety, and promote innovation in “individual-based” care (Hammond, Jaffe & Kush, 2009, p.44). The need for compliance with standards is fueled by their role in enabling aggregation of informa...
• Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
2. What are some of the advantages and disadvantages to having a standardized terminology within electronic health record
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
The Office of the National Coordinator for Health Information Technology (ONC) and CMS have adapted SNOMED CT as a medical terminology for Meaningful Use Stage 2, Electronic Health Record (HER) system, and health information exchange (HIE). SNOMED CT offers the clinical detail and terminological sophistication necessary for more effective use of clinical data to support timely, effective, and high-quality care. For example, SNOMED CT is an efficient documentation system that is highly recommended towards patient’s history and clinical procedures. When the ICD-10 CM was implemented, it impacted everyone who used it for diagnosis or inpatient procedure codes. In addition, SNOMED CT is not the only terminology that is used for healthcare needs, but RxNorm and LOINC are also
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
Health Information Management (HIM) professional: Will expect that the healthcare providers are honest, accurate in their diagnoses, and the charges are legal, fair, and correspond to services rendered on the given day. All inaccuracies must be corrected as soon as discovered to inspire confidence in the HIM professional, the facility, and all the organization’s employees. All stakeholders depend upon the HIM professional to maintain the accuracy, privacy and security of the patient’s medical charts, and thereby secure the reputation of the facility and welfare of the patients.
As technology continues to evolve, so does the need for healthcare facilities to continually maintain a higher level of competence that runs parallel to electronic and scientific advancement. Comparatively, the structure of hi-tech facilities, such as medical centers and clinics prepared with new amenities, has enhanced the industry scale of communities by working in the healthcare arena. Likewise, technological innovations which help diagnose a variety of infections and disorders has helped in assisting patients in receiving increased quality care. As a result, patient care as a whole has positively affected the population over the last decade. Furthermore, it only makes sense that more personalized and precise problem-solving methods and procedures will be devised in the future.
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’
Hospital Information System (HIS) and Radiology Information System
Introduction & Summary Clinical Decision Support systems are systems that aid in the provision of person-specific information and knowledge to patients, medical practitioners, clinicians and other persons within a health care setting. This person-specific information is presented and filtered according to the requirements in order to assist in enhancing the health care services and the general health of the patient. CDS system is comprised of a variety of tools including computerized reminders and alerts to healthcare practitioners and patients; focused summaries and reports of patient data; diagnostic support; order sets that are condition-specific; reference information with contextual relevance and documentation templates (Health IT 2013).
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.