NURS 8200 Week 3 Discussion: Controlled Terminology and Standards

Controlled Terminology and Standards Discussion – What are the advantages of standardizing coding terminologies? And what is the best way to achieve consistency for information systems?

As Dr. John Glaser notes in the “What Is Health Informatics?” media presentation (assigned in Week 1), a group of physicians may use many different terms to describe one patient’s painful experience. This simple example can be extrapolated to guide your thinking about the obstacles that have arisen for information system development because of the varied and complex nature of health care.

In this week’s Discussion, you evaluate the interoperability and coding challenges encountered in today’s health care organizations.

To prepare for Controlled Terminology and Standards Discussion:

• Think about how controlled terminology and standards facilitate information sharing, for example, sharing data between an emergency care clinic and a pharmacy or between a primary care physician’s office and a specialist’s office.
• Reflect on the national health IT agenda as presented in the Learning Resources.
• Consider challenges health care providers are facing in light of the national health IT agenda related to sharing data across information systems and/or controlled terminology standards. What strategies could a health care organization use to address interoperability challenges? Conduct additional research as necessary to determine possible solutions.

By Day 3 post a cohesive response that addresses the following:

• Evaluate the challenges that health care organizations may face when sharing data across systems.
• Using your professional experience and/or information gathered through research, provide at least two specific examples of interoperability challenges.
• Propose at least two strategies a health care organization might implement to address interoperability challenges.

Read a selection of your colleagues’ postings.

By Day 6 respond to at least two of your colleagues in one or more of the following ways:

• 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.
• Validate an idea with your own experience and additional research.
• Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
• Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.

Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.

Be sure to support your work with specific citations from this week’s Learning Resources and any additional sources.

Click on the Reply button below to post your response.

Controlled Terminology and Standards SAMPLE

Controlled Terminology and Standards

For enhanced consistency for information systems, there is a need to standardize coding terminologies as applicable in health care delivery systems. Different physicians use different terms to describe patient conditions, which pose obstacles that arise due to the varied and complex nature of healthcare (Ball et al., 2011).

Challenges Healthcare Organizations Face Sharing Data

Healthcare organizations face serious challenges when sharing data across systems. Among the major challenges include lack of interoperability and standardization across the health IT systems. Most of the health information systems are isolated within hospitals, physician practices, and pharmacies. There are also persistent changes in insurance cover and patients’ reliance on multiple providers that make the healthcare sector operate with different information that is fragmented and non-interoperable (Vest & Gamm, 2010). There is a need to change the isolated, fragmented health information for effective health information exchange between different organizations. The healthcare systems need to have improved interoperability with providers, policymakers, and patients to facilitate seamless exchange of health data between different IT systems (Ball et al., 2011). There lacks a standardized way of identifying patients, health IT interoperability standards across all settings, and industry-wide interoperability measurement standards. Such challenges make it difficult to share data across systems (American Nurses Association, 2008).

NURS 8200 Week 3: Controlled Terminology and Standards

Efficient, reliable, and interoperable information systems rely on consistent terminology and standards. Since the mid-1960s, the health care industry has attempted to align its codes and terminologies. This task has been challenging, however, because the myriad of clinical systems—from patient diagnosis to surgery—use terms and procedures that vary widely. As technology continues to develop and the health care industry progresses, organizations need to come together to achieve the complex goal of code compliance.

This week, you examine IT standards and terminologies, and consider the critical role they play in achieving technology interoperability.

Learning Objectives

Students will:

• Evaluate the challenges of sharing data across information systems
• Propose solutions for interoperability challenges

Photo Credit: alengo / E+ / Getty Images

Learning Resources

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.

Required Readings

Course Text: Ball, M. J., Douglas, J. V., Hinton Walker, P., DuLong, D., Gugerty, B., Hannah, K. J., . . . Troseth, M. R. (Eds.) (2011). Nursing informatics: Where technology and caring meet (4th ed.). London, England: Springer-Verlag.

• Chapter 13, “Standards and Interoperability

This chapter introduces the definition, standards, and challenges of interoperability. The authors also detail the impact that interoperable systems will likely have on the future of electronic health records (EHRs) in response to the national health IT agenda.

Course Text: American Nurses Association. (2008). Nursing informatics: Scope and standards of practice. Silver Spring, MD: Author.

• Trends in Care Delivery Models and Innovation” (pp. 63-66)

This excerpt gives examples of projects that are being used to accelerate informatics implementations in organizations.

Grain, H. (2010). Clinical terminology. Studies in Health Technology and Informatics, 151, 70-83.

Retrieved from the Walden Library databases.

This article begins with an historical overview of computer use in the health care industry. Then it takes an in-depth look at the incentives being used to increase the percentage of practice settings that comply with the integration of electronic health records and interoperable technologies.

Hovenga, E. J. (2010). National standards in health informatics. Studies in Health Technology and Informatics, 151, 133-155.

Retrieved from the Walden Library databases.

This article provides an in-depth review of the development of national standards. It includes a look at the components of standards and how they affect the interoperability of systems.

Kuperman, G. J., Blair, J. S., Franck, R. A., Devaraj, S., & Low, A. F. H. (2010). Developing data content specifications for the Nationwide Health Information Network Trial Implementations. Journal of the American Medical Informatics Association, 17(1), 6-12.

Retrieved from the Walden Library databases.

The authors of this article use the experiences of the Nationwide Health Information Network’s Trial Implementations project to describe the process and challenges of developing content specific standards.

Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal 39(2), 37-39.

Retrieved from the Walden Library databases.

Real-world examples are used in this article to predict how the management of health information will change as standardized terminologies are implemented within practice settings.

American Nurses Association (2006). ANA recognized terminologies and data element sets.
Retrieved from http://ana.nursingworld.org/npii/terminologies.htm

By navigating through this website, you can see the table that shows the data sets recognized by the American Nurses Association.

Centers for Disease Control and Prevention. (2009). Health data standards.
Retrieved from http://www.cdc.gov/nchs/about/health_data_standards.htm

This website provides a link to two organizations that focus on health standards and statistics. The first organization that you may choose to view is the National Committee on Vital and Health Statistics, which was established by Congress and advises the Department of Health and Human Services. The second is called the Public Health Data and Standards consortium, a not-for-profit organization that works with a variety of agencies, associations, and organizations.

Logical Observation Identifiers Names and Codes (LOINC®). (2011).
Retrieved from http://loinc.org

Access this website to gain information on LOINC’s universal coding system for laboratory and clinical observations.

Saba, V. (2011). Clinical Care Classification System.
Retrieved from http://www.sabacare.com/

At this website, you can view the framework of the Clinical Care Classification (CCC) coding structure. Use the side tabs to view the features that make this coding terminology widely accepted as a means to document patient care in electronic health care records.

U.S. National Library of Medicine. (2011). Unified Medical Language System® (UMLS®).
Retrieved from http://www.nlm.nih.gov/research/umls

The Unified Medical Language System uses its three tools, or Knowledge Sources, named Metathesaurus, Semantic Network, and SPECIALIST Lexicon and Lexical Tools to combine many popular standards and terminologies used in the health care industry. This integrated system facilitates interoperability between computer systems.

Required Media

Laureate Education, Inc. (Executive Producer). (2011). Transforming nursing and healthcare through technology: The standardized representation of health information. Baltimore, MD: Author.

Note: The approximate length of this media piece is 16 minutes.

This week’s media presentation introduces the importance of standardized data in interoperable systems.

Accessible player–Downloads–Download Video w/CCDownload AudioDownload Transcript

Optional Resources

ABC Coding Solutions. Retrieved from http://www.alternativelink.com/ali/home/

NURS 8200 Week 3 Discussion: Welcome to the Week 3 Discussion area!

Post your responses to the Discussion based on the course requirements.

Your Discussion postings should be written in standard edited English and follow APA guidelines as closely as possible given the constraints of the online platform. Be sure to support your work with specific citations from this week’s Learning Resources and additional scholarly sources as appropriate. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct. Initial postings must be 250–350 words (not including references).