NURS 6401 week 8 Discussion Essay
The Standardization of Health Care Terminologies
Healthcare terminology can be complex, to say the least. I learned this lesson time and time again while working as a hospital unit coordinator, a women’s clinic assistant, and a medical biller. For the last 10 years, however, I’ve been in the healthcare IT side of the business, which gave me the opportunity to take part in development, implementation, and maintenance projects. And every step of the way, I’ve worked to ensure that healthcare terminology standards were used effectively.NURS 6401 week 8 Discussion Essay
When I tell people what I do, there is always some level of confusion. What do you mean by healthcare terminology? Do you maintain the medical dictionary? Well, not exactly … but sort of. While terminology can refer to a number of different things in healthcare, the terminology I’m referring to is associated with electronic health records (EHRs) and the “language” used to code entries in these records including ICD-9, ICD-10, LOINC and SNOMED, among others.
In the world of electronic health records (EHRs), terminology is one of the keys to true interoperability between systems and integrating data. Say, for example, you want to send data between two systems. For the data to be usable, those systems have to “talk” to the same language. This means codes from one system have to be mapped to the codes from the other system. While you can combine data from multiple systems in one place, if you’re not mapping those codes to one another, you’re not unlocking the data.
Healthcare billing systems have been using terminology standards for many years and healthcare organizations have complied with these standards. Why? Because people will always comply with a standard when money is on the line. (With billing systems, if you don’t send the codes in a terminology that’s requested, claims don’t get paid.) The result is that, now, standard billing terminologies like Current Procedural Terminology (CPT®), International Classification of Diseases (ICD), among others, have a clear place in electronic systems.
But on the patient-care side of systems, terminology standardization is just beginning to get the attention it needs. Why has it taken so long? First, because clinicians often favor customization over predefined lists of questions and drop-down menus that often come with standardization. Plus, healthcare is more complex than other industries – which means standardization associated with the uniqueness of care is just simply hard to do. From my experience, it’s difficult enough to get one organization to agree on a standard for something, let alone the whole country to agree – and beyond.NURS 6401 week 8 Discussion Essay
Thankfully the informatics community has been working on these terminology standards for years. They recognized the potential and power of healthcare terminology standardization. It’s because of these efforts that we have more mature standards like Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC). These and other standards are referenced by many initiatives including Meaningful Use. These initiatives are being developed to encourage more broad adoption of standardization so the benefits of using consistent terminology can be more rapidly realized. EHR vendors are also incorporating standards in certain areas of their applications increasing the efficiency of data exchange.
Terminology standards facilitate decision support, consistent reporting and analytics in addition to interoperability. There is a lot of potential, but it also comes at a cost. Implementation is difficult and generally requires a lot of tedious mapping work. Thankfully the tools available in the market are improving, so mapping local codes to standards and maintaining those mappings is becoming easier.
As we progress through this era of standardization and interoperability, terminology standards will become much more prevalent and understood. They have a big role to play and will continue to become more prevalent in various healthcare systems to facilitate data consumption objectives.
what is the Importance of Medical Terminology in the Health Care Field?
With today’s emphasis on good healthcare, along with the increase in malpractice lawsuits, the importance of medical terminology in the healthcare field has never been stronger. This terminology is used throughout the healthcare industry from health information management (HIM), the provider and payer right down to the patient. For many reasons, it’s vital that everyone be “on the same page” in regards to correct medical verbiage at every level of healthcare.NURS 6401 week 8 Discussion Essay
Improves Patient Care
Often patients don’t understand the terminology that doctors use when discussing their condition or their treatments. The patient may ask the nurse what the doctor meant, but if they don’t understand either, there can be a lot of confusion. When all members of the healthcare team use the same terminology, they can explain it to the patient. Good patient education can not only lead to satisfaction but can also make the patient more eager to be involved.
Makes for Standardized Care
Healthcare terminology has long been an important part of the healthcare industry and has been referred to as the language of medicine. With electronic health records being used everywhere today, healthcare terminology must be used by not just humans but on computers as well. This terminology is used in specific medical terms and codes. According to The American Health Information Management Association, there are four different types of codes used in healthcare: administrative codes, clinical codes, reference terminologies, and interface terminologies.NURS 6401 week 8 Discussion Essay
With medical professionals all understanding and using the same codes and terminologies, they’re able to communicate effectively. When they’re all using the same medical or healthcare terminology, they’re all able to do their part in providing the best in healthcare be it a medical procedure, a health condition or prescription drugs. Whether it’s HIPAA compliance training, staff instructions or reading a patient’s chart, everyone understanding and using the same terminology makes for standardized care throughout.
Better Patient Safety
Patient safety is of utmost importance to prevent accidents, healthcare complications, and lawsuits. When quality and standardized communication is used by everyone who is part of the healthcare team, there is less chance of mistakes being made. For example, if the doctor can clearly read a patient’s chart, it helps the doctor provide an accurate diagnosis and treatment plan. If the wrong medical terminology is used, it can drastically change the care the patient receives. A wrong diagnosis or wrong treatment plan can be harmful or even fatal.
More Efficiency in Health Care
With all the patients a healthcare professional sees throughout the day, they may not always have time to write long descriptions in the charts. Even if they did, nurses and other physicians might not be able to understand what’s written. By all medical personnel using the same medical or health terminology, they can all understand what’s on the patient’s chart and provide them with the best possible care. Additionally, time isn’t wasted having to ask what’s written on the patient’s chart. Medical codes and terminology are also used for the billing and reimbursement process, which also adds to patient overall care because there’s less chance of the patient being billed for the wrong procedure.
Doctors, nurses and every member of the healthcare team have usually chosen their careers so they’re in positions to help others. Knowing and acknowledging the importance of medical terminology in the healthcare field is an important part of providing that help.NURS 6401 week 8 Discussion Essay
The continued development of new imaging techniques in urology has had considerable impact on both clinical practice and urologic research [1,2]. The clinical integration of these imaging techniques into urologic practice involves contributions from investigators and clinicians of varied backgrounds including physics and engineering, informatics, urology, and radiology. Each profession has its own jargon, a specialised language that allows for rapid and efficient communication between members of the same profession while minimising the potential for misunderstandings. Abbreviations are an extension of the jargon of each profession, and they enable health care professionals to document their work more easily and communicate quickly.
Abbreviations have generally been adopted on an ad hoc basis to accommodate the often conflicting demands of utilising brief context-sensitive phrases and combinations of letters with the challenging requirements of more rigid, computer software-driven, clinical and research practice; however, this jargon might lead to the problem of several terms for the same object. The differences in terminology and the lack of standardisation of the terminology can lead to confounders, errors, and misunderstandings as well as to loss of information and knowledge.
Most of this development and expansion of terminology has occurred in an unplanned and uncoordinated manner and has been adopted through common usage within specialities rather than by consensus agreement [3]. Various lists of abbreviations and terminologies have been produced by different speciality groups [4,5]. During the review, it was found that a wide variety of terms were used for the same examination, for example, Intravenous Urogram (IVU) was also termed Kidney, Ureter, Bladder (KUB) Urogram or Urography.
Much of this usage has been driven by agreed common practice without reference to any unifying standard of methodology or taxonomy. Taxonomy is a general principle of scientific classification. Organisms are classified into a hierarchy of groupings. The order of ranking is usually from the more general to the more specific to describe and reflect a morphologic relationship [6].NURS 6401 week 8 Discussion Essay
There has been a general lack of international co-operation among different specialities and among different geographic locations for the same speciality. Confusion between the different requirements for digital archive coding systems and research may cause a lack of support to integrate data produced by everyone involved in urology imaging and further promote a diversity of interests.
The benefits of a shared nomenclature for literature research and communication among clinicians are obvious. The absence of agreed on operational nomenclature will inevitably undermine the yield from literature review if different search terms are used. The aim of this work is to review the current nomenclature used for imaging in urology in clinical practice and in the published literature and to propose standardization of terms using taxonomy.NURS 6401 week 8 Discussion Essay