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?

 

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 NURS 6411: Week 11: Standardized Terminologies Applied to Health Care

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 – NURS 6411: Week 11: Standardized Terminologies Applied to Health Care

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.

 

• 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

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. NURS 6411: Week 11: Standardized Terminologies Applied to Health Care.

 

 

 

ADDITIONAL INFO 

Standardized Terminologies Applied to Health Care

Introduction

A standard vocabulary is a necessity for precise communication among health care professionals. It improves quality and efficiency, helps to eliminate ambiguity and promotes trust between patients and their doctors.

In a Health Care context, the use of standardized terminologies is critical to improving quality and efficiency.

A standardized terminology is a set of terms and their definitions that are used to describe concepts in health care. It is necessary for computerized decision support requested by health care professionals, because it enables them to make sense of the information they receive and give it meaning. Standardized terminologies enable consistent understanding of medical concepts or entities, which allows them to be applied across multiple disciplines and information domains in health care.

Computer-readable and machine-readable terminologies are necessary for computerized decision support requested by health care professionals.

Computer-readable and machine-readable terminologies are necessary for computerized decision support requested by health care professionals.

Computerized decision support is used to improve quality and efficiency of patient care by providing information to clinicians in a structured format. This can be done through electronic health records (EHRs), which collect patient data from different sources, such as medical records, imaging tests, lab reports and other clinical data into one database that can be accessed by authorized users within the organization or outside of it for further analysis or research purposes. These systems also allow for easier communication between patients and healthcare providers who need more information about their condition at any given time; thus improving efficiency while reducing costs associated with unnecessary redundant tests performed during an appointment visit where there isn’t enough time left over after all the questions have already been asked!

A terminology enables a consistent understanding of medical concepts or entities.

To enable a consistent understanding of medical concepts or entities, it is necessary to establish a standard vocabulary. A standard terminology enables a consistent understanding of medical concepts or entities. The use of standardized terminologies in health care improves efficiency and quality.

Terms used in a specific context have unique meanings.

Terms used in a specific context have unique meanings. For example, the term “health care” refers to the medical treatment of people, whether they are sick or not. The term “health care system” refers to the organization that provides this treatment and everything attached to it (e.g., doctors, nurses).

The terms used in health care are often interrelated: for example, you can’t get comprehensive health care without being able to pay for it; thus if an individual’s ability-to-pay restricts access to services like mental healthcare or dental care then these will be excluded from consideration when determining eligibility under Medicaid coverage guidelines even though they may be available through other insurance plans such as Medicare Part D prescription drug plan coverage which typically includes all drugs approved by FDA approval standards but excludes generic equivalents unless specifically prescribed by licensed practitioners who have been certified according to state licensing laws governing their profession

Standardized Terminology can be applied to several disciplines and information domains in health care.

Standardized terminology can be applied to several disciplines and information domains in health care. The most obvious application of standardized terminology is the use of standard nomenclature for human anatomy, physiology, pathology and pharmacology. Standardized terminologies have been developed for these fields by various organizations such as the International Committee on Medical Nomenclature (ICMN).

In addition to human anatomy and physiology, there are many other fields where the use of standardized nomenclature is critical for precise communication among health care professionals:

• Infectious diseases have been classified into syndromes based on symptoms; this classification system allows faster diagnosis and treatment decisions based on signs rather than symptoms alone. For example, cholera patients show vomiting or diarrhea with loss of appetite due to dehydration caused by an increase in water consumption.-1

A standard vocabulary is a necessity for precise communication among health care professionals.

A standard vocabulary is a necessity for precise communication among health care professionals. Standardized terminologies are a prerequisite for computerized decision support and other information-based systems that help physicians make informed decisions about patient care. They also allow patients to understand the language used by their doctors, which can reduce misunderstanding and provide better outcomes for both parties.

Standardized terminologies are applied in multiple domains and disciplines in health care, including:

• Diagnosis (i.e., what’s wrong with me?)

• Treatment planning (i.e., how do I get better?)

• Monitoring compliance with treatment plans by physicians or nurses

Conclusion

The use of standardized terminologies is a key element in the improvement of quality and efficiency in health care. However, the implementation of this technology requires a high level of expertise that can only be obtained through intensive training programs. In order to provide these types of services, we need more professionals who are able to provide medical terminology services and translate different medical terms into common English or Spanish.