Question

The main challenges being the standardized nursing terminology and benefits?

Answer 1

Ans. As a registered nurse , I’m in the field of medical and nursing terminologies within electronic health records . I understand all too well the impact and benefits that standard healthcare terms contribute in leveraging interoperability and providing healthcare with big data for research and population health, and why it’s a lot easier said than done.

Physicians, nurses, and other healthcare professionals face numerous challenges when documenting their assessments and diagnoses with associated labs, tests, and procedures located within an EHR from standardized coding systems.We are forced to sometimes associate tests and procedures with diagnoses or conditions that aren’t exactly what the patient presents with. A good example of this is when a patient presented with lower abdominal pain and upon further examination and diagnostic CT, the patient was found to have a somewhat rare condition called epiploic appendagitis. When the physician was forced to pick from a list of codes to associate the CT scan he ordered, there was no option for epiploic appendagitis so he went with the next best option, diverticulitis. These two conditions are not one in the same and showcases some of the obstacles healthcare providers face when having to pick from a list of standardized terminologies within an EHR.

Another impediment that some physicians express, is the amount of effort that is put towards trying to find the right diagnosis from a list of standardized terminologies, as this takes away valuable face time with patients. The challenge behind standardization is mainly due to the fact that the medical field is vastly complex and ever changing so it is nearly impossible to come up with one standardized list of terminologies across the board that satisfy everyone’s needs. Also, due to the variation of vocabularies found within different EHRs, mapping presents a major hurdle to interoperability.

Another impediment that some physicians express, is the amount of effort that is put towards trying to find the right diagnosis from a list of standardized terminologies, as this takes away valuable face time with patients. The challenge behind standardization is mainly due to the fact that the medical field is vastly complex and ever changing so it is nearly impossible to come up with one standardized list of terminologies across the board that satisfy everyone’s needs. Also, due to the variation of vocabularies found within different EHRs, mapping presents a major hurdle to interoperability. It also begs the question of how to continually update the standardized lists as new terminologies are created and old ones are retired? But without standardization, how do we overcome the uphill battle of interoperability and communication between a myriad of EHRs and terminologies?

Benefits :- The advantages of standardizing healthcare terms outweigh the major efforts to combat the issue around unstructured data and interoperability. There are several national initiatives that share the goal of standardizing vocabularies within EHRs to facilitate the transfer of data, information, and knowledge among systems with the ultimate goal of interoperability. Meaningful use being one of the main drivers for interoperability with a foundation based upon priorities to improve quality, safety, efficiency, population and public health, and reducing health disparities. Finding a way to overcome the variability in which clinical data is portrayed, is extremely important in interoperability and big data. We have all this clinical data within EHRs, databases, and data warehouses that can be used for research and population health, but we are unable to easily extrapolate this data due to the lack of standardized terminologies and unstructured data.

Terminology :- Nurses provide more direct patient care than physicians and therefore, provide extensive ongoing documentation regarding assessment, treatment, and outcomes of patient care. I’m somewhat partial to this subject and to the fact that you mostly only hear about standardized medical terminology.

Documented nursing care tends to go under the radar when it comes to hospital and accounting information systems and EHRs. One of the major contributors to this phenomenon is the lack of structured nursing data to represent the care that nurses provide. It’s just as important to continue to support and produce a scientific classification of nursing work as it is in medicine. Standardized nursing data has the ability to provide decision support, discovery of disparities, reporting of outcomes, improved performance, maintenance of accurate problems lists and medications.

It’s not just medicine that faces this daunting challenge of finding a way to create interoperability through standardized healthcare terms. All realms of patient care, including nursing are affected since interoperability is reliant on medicine and nursing working together to overcome this national and global obstacle.