(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 …show more content…
Interface terminology maps the terms that providers have in minds with the administrative codes. The process helps the providers to focus on their patients while spending less time finding the appropriate codes for their recorded terminologies. The authors also demonstrate the importance for health information management (HIM) professional to acknowledge the significant role of interface terminology in EHR. HIM professionals play a key part in healthcare organizations’ workflow to harvest all benefits of the systems to maximize healthcare organizations’ profits. Interface terminology affects the providers’ documentation experiences and the healthcare organizations’ revenues. The authors state that interface terminology is vital to healthcare as it serves as a foundation in improving providers’ documentation process and quality of patients’ …show more content…
In 2003, the U.S. National Committee on Vital and Health Statistics recommended a set of standardized terminologies to portray the patients’ conditions their medical record. These terminologies sufficiently represent the patients’ medical information and meet the requirement to serve as reference terminologies. For example, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is used to aggregate, exchange and analyze patients’ medical information. Logical Observation Identifiers Names and Codes (LOINC) represent laboratory tests. RxNorm and National Drug File Reference Terminologies are used to demonstrate the biological mechanisms of actions and effects of medications. The number and size of clinical terminologies have been expanding over time since there are more and more new diseases’ diagnoses have been found. The requirement for providers to document patients’ information using the federal standardized terminologies and codes is overwhelming the providers all over the country. It takes the time, which is supposed to be spent with patients, so providers can pay more attentions to complete documentation as requested. The developing of interface terminology has helped solve the problem. Interface terminology translates providers’ own language into more structured industrial application languages, which are apply
Legally enforceable "A contract is a legally enforceable promise or set of promises. In other words, when promises have the status of contract, the contracting party harmed by a breach of the contract is entitled to obtain legal remedies against the breaching party." (Scheffel, Evan, and Jane P. Mallor, 2010. Chapter 9, Page 321) The Lambert v. Barron case showed us an example of what happens when a contract does not contain all elements to become a legally enforceable contract. Mr. Barron did not accept the offer, Mr. Lambert made no promise to recover money from the disputed contracts owed to Mr. Barron, so there was no promise to perform.
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.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
(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.
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an incentive, the government began issuing payments to those providers who “meaningfully use certified electronic health record (EHR) technology.” (hhs.gov) There are three stages that providers must progress through in order to receive theses financial incentives. Stage one is the initial stage and is met with the creation and implementation of the HER in the business. Stage two “increases health information exchange between providers.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) Stage three will be the continuation and expansion of the “meaningful use objectives.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) The hospital, where I work, initiated the HER mandate many years ago. In this paper, I will discuss the progression and the challenges that my hospital encountered while implementing the EHR mandate.
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.
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
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.