The purpose of this literature review is to explore vast articles in regards to Controlled Medical Terminology in the healthcare industry and its goal to provide medical vocabularies compatible to various applications and usage among healthcare clinicians and consumers. Focusing on the correlation between Electronic Health Record and Controlled Medical Terminology ability to communicate effectively, structured, accurate and consistent with current practice to safe guard patient data for end users. Search Methods The literature are cumulative of qualitative studies and systematic reviews. By way of Overlook Medical Center (OMC) librarian who was extremely helpful in combining and limiting key word searches utilizing OVID MEDLINE, …show more content…
Due to the continuous effort to uniform Controlled Medical Terminology numerous amounts of healthcare professional are tapping into and or required to utilize Electronic Health Records (EHR) in compliance with governing agencies. Controlled Medical Terminology (CMT) creates a template for data exchange and standardization of medical terminologies as a requirement for interoperability. By addressing these issues a uniform solution must follow creating standards that all systems can talk to each other efficiently and surpassing continuity of care and opening fluent communication for patients. Healthcare Code Sets, Clinical Terminologies and Classification Systems are the focus of healthcare professionals transcending between unstructured to structured common language within the realm of Electronic Health Records …show more content…
Two articles (AMIA Symp. (2001), pp. 329-333) and (AMIA Symp. (1999), pp. 107-111) explored the relevance between studies “mediate between user terminology and terminology as it is reflected in a variety of medical information resources.” Various systems inclusive of UMLS, DARE, MEDLINEplus, SNOWMED CT, NLM, MeSH, Planetree Classification, AIRS and CINAHL search terms by means of clinician or consumer. According to Zielstorff (2003) solutions have been developed to solve the consumer vocabulary problem. Intelligent Medical Objects has developed the Personal Health Terminology (PHT) by mapping the most common terms in structured nomenclatures to consumer-friendly synonyms, thus performing a “translating” function. Developing word match, stem search and sound a-like features within search engines enable users to enter one term while populating comparable terms i.e. “nosebleeds” “epistaxis.” An “interface terminology” has been developed by Wellmed (2003) to facilitate the interaction of consumers and patients with professional concepts and information. These reports provide evidence that even when the matching rate is improved with manual extraction, string normalization, coding, and mapping, a significant portion of consumer terms are simply not found in professional nomenclatures. It seems clear that some bridging technology is needed to foster comprehensive bi-directional
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.
How would you define standardized terminologies and why are they important? Provide an example in your answer.
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
(Charles R. McCornell, 2015, pg 514) This title is the one that has had the most affect on patients and healthcare systems. “The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data.” (HIPAA Title Information, 2015, par 2) Switching over to electronic forms allows for administrative simplification, and the codes used for each location, individual, insurance helps reduce
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.
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
Bags and purses in schools have changed from being the schools property to personal property, because of one case. The New Jersey v. T.L.O court case gave a student a way to change privacy for students nationally. Even though in some situations the use of bags are turned into the institution belongings. It started with one flame in a foul school restroom with 2 negligent girls , both eager for a whiff of smoke. The teen had made the situation escalade by lying about even smoking the cigarette, which the school had curiosity about. Only the case didn't slide through the courts with ease there were many setbacks and misconceptions. The light of the case came from the existence of the fourth amendment dealing with personal privacy and reasonable
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
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
Physicians, administrators, staff, and patients who are affiliated within the healthcare organization should understand the importance of interoperability by coming together to ease ...
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.
(Bronnert, Masarie, Naeymi-Rad, Rose, & Aldin, 2012)In this article, the authors have shown the important of interface terminology acting as a bridge that links the works of providers and the information that is interpreted and stored in electronic health record (EHR). The authors explain the definition of terminology as a set of descriptions used to represent concepts specific to a particular discipline. Each terminology has its unique purpose and attribute. Today, a single patient’s EHR requires many terminologies using different coding systems, which create the gaps in linking the clinical codes between those systems. Furthermore, providers are forced to use administrative coding sets, such as CPT, HCPCS, ICD-9-CM, which are used to support