Discussion: Standardized Terminologies in Health Care Databases
Discussion: Standardized Terminologies in Health Care Databases
NURS 6411: Information and Knowledge Management | Week 11
How important is it to use standardized terminologies and encourage collaboration in health care organizations?
Imagine you are treating a patient who is expressing a problem with breathing. You carefully record in his chart that he has shortness of breath. After the doctor performs her exam, she states that the patient is suffering from dyspnea. When you discuss the case with a fellow nurse, she remarks that she has seen such cases before and it is certainly caused by abnormal breathing patterns. All three diagnoses actually refer to the same condition. The real problem occurs when the information is entered into a database. Which term should be used? Later, if you are trying to identify patients with similar conditions, would you miss some because of the varying terminologies? Discussion: Standardized Terminologies in Health Care Databases.
Similarly, multiple health care organizations can each have specific data about a patient or illness, but unless the data terminology is standardized, the value of the database system is limited. This standardization is conducive to improving patient care and reinforcing productive communication between nurses, doctors, and other health care personnel.
This week, you familiarize yourself with the importance of standardized terminologies for data storage and retrieval. You also focus on the relationship between clinical information systems and standardized terminologies in database design.
Learning Objectives – Discussion: Standardized Terminologies in Health Care Databases
Students will:
- Assess the use of standardized terminologies in databases and clinical information systems
- Analyze the importance of standardized terminologies for data retrieval
Learning Resources
Required Readings
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Hammond, W. E., Jaffe, C., & Kush, R. D. (2009). Healthcare standards development: The value of nurturing collaboration. Journal of AHIMA, 80(7), 44–50. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_043995.hcsp?dDocName=bok1_043995
The authors of this article explore the effect that differing standards have on the health care field and how collaboration can help move standardization processes forward.
Dontje, K., & Coenen, A. (2011). Mapping evidence-based guidelines to standardized nursing terminologies. Computers, Informatics, Nursing, 29(12), 698–705
This article explores ways to standardize data terminology and data storage for increased diagnostic and treatment efficiency. The authors evaluate the utilization of standardized nursing terminologies and evidence-based guidelines with depression cases to pinpoint efficient implementation techniques and techniques that can still be improved.
Hayrinen, K., Lammintakanen, J., & Saranto, K. (2009). Evaluation of electronic nursing documentation—nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79(8), 554–564.
The authors of this article discuss the relationship between nursing processes and the development of more complete and comprehensive electronic health records (EHRs). In addition, they evaluate the motivations behind standardizing data for universal comprehension and application.
Thoroddsen, A., Ehnfors, M., & Ehrenberg, A. (2011). Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records. Computers, Informatics, Nursing, 29(10), 599–607.
In this research study, the authors performed audits of patient records to examine issues regarding documentation terminologies in patient care. The study revealed the need for standardized nursing terminologies and the role of these terminologies in improving the accuracy of evidence-based diagnoses.
Frisher, M., Short, D., & Bashford, J. (2010). Determining patient characteristics for decision analysis support systems using anonymized electronic patient records. Health Informatics Journal, 16(1), 49–57
This article reports on a study conducted with stroke patients that examined how decision analysis support systems can be applied. The authors discuss how evidence-based consultations of patients and data analysis can improve decision making.
Huryk, L. A. (2012). Information systems and decision support systems. American Journal of Nursing, 112(1), 62–65.
The Health Information Technology for Economic and Clinical Health (HITECH) Act has encouraged the implementation of technologies in evidence-based practice, diagnostics, and research. One result of this is the growing reliance on decision support systems in patient care. The author of this article examines how the nursing field and curricula are adapting to meet this change in practice.
Ensuring data integrity. (2009). Nature Neuroscience,12(10), 1205.
This article explores methods that health care organizations can employ to ensure the integrity of collected and stored data.
Required Media
Laureate Education, Inc. (Executive Producer). (2012). Standardizing nomenclature. Baltimore. Baltimore, MD: Author.
Note: The approximate length of this media piece is 6 minutes.
Roy Simpson describes the importance of standardizing clinical language using nomenclatures, or methods of coding clinical information
The following document provides credit for all Laureate-produced material in this course: Credits (PDF)
Discussion: Standardized Terminologies in Health Care Databases
Have you ever traveled abroad and asked for directions from someone who did not speak your own language? Perhaps you unsuccessfully attempted to use Google Translate or tried gestures and hand signals to communicate your request. The ability to communicate in the same language greatly increases the likelihood of shared understanding.
In health care, having a standard terminology facilitates the flow of information. Just as two people who speak different languages have difficulty understanding one another, so will two databases that utilize differing sets of terminologies. Standardized, shared terminologies enable database systems to effectively communicate.
To prepare:
- Review this week’s Learning Resources focusing on the significance of standardized terminologies in health care settings. Consider how standardized terminologies are important in the development and use of databases and clinical information systems.
- Explore the websites of major health care organizations to determine their recommendations on acceptable standardized terminologies.
- Determine the standardized terminologies currently used by your health care organization (or one with which you are familiar).
- Consider the standard terminologies (recommended by a major medical organization or based on your experiences) you would like to see incorporated into your organization’s databases and clinical information systems. What would be the benefit of using these particular standards? How might this impact the quality of the information retrieved from databases within your organization?
By Day 3 Discussion: Standardized Terminologies in Health Care Databases
Post a description of at least one standardized terminology that is recommended by a major health care organization. Assess how or if this terminology is incorporated into your organization’s databases and clinical information systems. Identify at least one additional standardized terminology you would like to see incorporated into the organization’s databases. Analyze the importance of incorporating this terminology and how this could impact the quality of the data retrieved from the databases. Justify your response.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days using one or more of the following approaches:
- Ask a probing question, substantiated with. additional background information, evidence, or research.
- Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
- Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
- Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings. Discussion: Standardized Terminologies in Health Care Databases
Standardized Terminologies in Health Care Databases
Introduction
Since the beginning of modern medicine, healthcare professionals have used standardized terminologies to communicate with each other. These terms are important because they allow doctors and nurses to share information quickly and easily by using familiar language. They also help ensure that patients receive the best care possible while ensuring consistency across all practitioners who use this type of vocabulary.
What is a standardized terminology?
A terminology is a set of terms used to describe a subject area. Terminologies are used in health care databases to describe patients, diseases, procedures and other types of data.
A standardized terminology is one that has been created by an organization or group with the goal of ensuring that all people using the same term have the same meaning when they use it. The process by which these terminologies are developed includes researching existing definitions and proposing new ones based on existing standards within the field (for example: American Medical Association).
Why does the health care industry need to standardize terminologies?
Standardized terminologies are needed to enable the exchange of data between health care providers. For example, if a patient is admitted to a hospital and has not been diagnosed with any disease yet, but his or her symptoms suggest he might have cancer, it would be helpful to know that this patient has been admitted to the hospital before being diagnosed with cancer. This information can be stored in a standardized terminology system as part of an individual’s record so that doctors and nurses do not need to manually enter each piece of information into their own databases when they see patients in different settings (e.g., emergency room vs outpatient clinic).
Why do we need different versions of SNOMED CT?
SNOMED CT is a comprehensive, all-in-one health care terminology. It can be used for clinical and administrative purposes.
SNOMED CT is divided into three versions: Version 1 (V1), Version 2 (V2) and Version 3 (V3). V1 was originally developed in 2004 by the National Library of Medicine as a standard for medical records; V2 was updated in 2010 to support advanced searching capabilities; and V3 was released by NIMH in April 2018 with new features such as improved analysis tools and access control capabilities designed specifically for clinical research settings.[7][8]
How is SNOMED CT related to ICD-10-CM codes?
SNOMED CT is a standardized terminology used in health care databases. It’s based on ICD-10-CM codes, which are a set of codes that are used by health care professionals to describe diseases and other medical conditions.
ICD-10-CM codes can be used with SNOMED CT diagnoses to help you understand what the diagnosis means in your patient’s case.
SNOMED CT is a standard for using medical terms. It’s a set of codes that define the meaning of words and phrases used by health care professionals. SNOMED CT is used in many electronic health record systems and other health information systems, including those developed by Epic Systems Corp., Cerner Corp., AllScripts Inc.
Why do we need different versions of LOINC (Logical Observation Identifiers Names and Codes)?
LOINC is a family of standards that define how to store, process and display clinical observations, laboratory tests and radiology studies in a structured way. In short, LOINC codes are used for clinical observation and laboratory tests. The term “LOINC” itself refers to the logical observation identifiers; it does not refer to any specific standard or format. The LOINC system uses three different codes:
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Standard Number Code (SN) – A number representing an observation’s type (e.g., blood glucose level).
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Name/Description Code (NDC) – For example: diabetes mellitus, subjective fever; objective temperature >37°C
How is SNOMED CT related to LOINC codes?
SNOMED CT is a superset of LOINC codes. In other words, it is a reference terminology that includes both the clinical data elements and the LOINC code sets.
The relationship between SNOMED CT and LOINC has been in place for many years now, but it’s important to understand how this works so you can use your existing databases more effectively by adding new terms or modifying existing terms in order to be consistent with your local standards.
SNOMED CT is a clinical terminology that helps to improve the exchange of information between different healthcare providers and organizations. It includes over 300,000 terms, which are organized into 21 areas of clinical medicine.
Standardized terminologies enable us to use consistent language when working with health care databases.
Standardized terminologies enable us to use consistent language when working with health care databases.
Standardized terminologies are a set of terms that are used consistently across all health care databases, so you don’t have to search for the right word or phrase when talking about your data. For example, if you’re looking at a patient record and need to know what the doctor wrote on their prescription form, you can quickly look up “prescription” in your database and see whether there’s anything similar written on another document. This saves time because it allows people who work with multiple documents at once (like surgeons) or those who want quick access but don’t want an entire special vocabulary loaded into memory (such as nurses).
Conclusion
We can now see the benefits of standardizing terminologies. By using one version of a healthcare database, we have access to all the medical terminology used by doctors and other professionals. It makes it easier for them to communicate with each other and allow us to do our work in a more efficient manner.
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