Accurate Electronic Patient Charts — A Standardized Clinical Language Is Key to Success
By Cynthia B. Lundberg, RN, BSN
For The Record
Vol. 20 No. 20 P. 6
The current state of information exchange in the healthcare community is one of flux as it transitions from paper-based to computerized records. Treating patients in a variety of settings across the entire healthcare continuum requires sharing the most accurate and up-to-date information among a multitude of providers and facilities.
Healthcare organizations around the world are working to integrate electronic health records (EHRs) as a means of sharing chart data electronically between other departments and facilities. The entry of more comprehensive EHRs into the marketplace is likewise an attempt to capture, store, and share patient data from a single location. The inability to access accurate healthcare data can be a distinct barrier to providing the best possible patient care.
Interoperability at these levels is only possible when the information itself can be shared among the many different sites involved in a patient’s care. Clinical data for health information systems need to be recorded at the appropriate level of detail, remain consistent over time and across boundaries, and be able to be transmitted without any loss of meaning and accuracy. Further, it needs to be aggregated at more general levels for analysis purposes and interpreted by automated systems to save time and resources.
The key to achieving interoperability is through standards for data capture, storage, messaging, and, most importantly, the use of standardized clinical terminology. SNOMED Clinical Terms (SNOMED CT), for example, can be used to exchange data from one facility to another to support research and analysis.
Across the country and the world, different clinicians have many different ways of referring to the same common conditions. For example, one clinician may record a “temperature regulation,” while another dubs it a “body temperature modification and control,” and a third documents “implements thermal regulation measures.” To a healthcare professional, they all represent the same intervention, but to a computer, they mean separate things.
To avoid these discrepancies, a common language is needed that can identify all possible variations and translate healthcare terms into an accepted, standardized clinical terminology presented in a language that clinicians can understand. Obviously, if a clinician can’t use patient information or receives incorrect data, the assurance of accurately researching and exchanging EHRs is not achievable.
Without a common method for capturing, storing, and aggregating patient data according to a standard terminology such as SNOMED CT, the potential for patient errors can increase, while data reliability and validity are reduced. The use of standardized clinical terminology makes data easier to share and use and is therefore a greater benefit to clinicians, and it supports data extraction for clinical research and reporting.
Using standardized clinical terminology allows accurate health information to be shared across departments and facilities. Additionally, extracted stored information can be the backbone of decision support and evidence-based practice research used at the point of care.
Therefore, when storing chart data, they must also be in a common vocabulary. That way, if clinicians are trying to find data, they’ll have material that conforms to accepted standards. For example, when mining and searching for temperature regulation, the system will also find all synonyms of temperature regulation. Also, when the aim is to capture rather than just store data, they must be captured in a similarly structured format for data to retain meaning, value, and ongoing usability.
For EHR initiatives to succeed and achieve the goal of providing the best patient care, it is imperative to have a consistent method for storing, retrieving, and aggregating data for use in various areas. Understanding that there are any number of areas (hospitals, physician’s offices, home healthcare settings, etc) where that information will be required, standardized clinical terminology becomes a tool to extract the data in a manner that is meaningful to clinicians.
A common clinical language also facilitates interoperability of systems, which results in better patient outcomes and operational and financial benefits to healthcare providers. If attending clinicians have a clearer picture of a patient’s history instead of having to rely on the patient recalling his or her various conditions, medications, and treatments, it will not only produce improved outcomes but will also reduce treatment costs.
There is also value to be derived from maintaining the continuity of care. Today, it is understandable for patients to expect doctors to have access to consistent, reliable information relating to their health history and care processes. With standardized clinical terminology, all patient data would be available across the full spectrum of healthcare settings: family history, medications, allergies, diseases, and treatments that can be coded and shared among clinicians, sites of care, and even national and international geographic boundaries.
For the clinician, access to this level of knowledge will ultimately result in the delivery of improved, safer care. When integrated into an EHR software system, standardized clinical terminology enables primary and specialty care providers to share comparable data at any time, from any place.
To support informed decision making in patient care and to maximize patient safety, a robust clinical terminology such as SNOMED CT can be used to develop the knowledge-based relationships within an EHR. For example, allergies must be linked to drugs and contraindications and procedures to devices. The use of common language across clinical domains, at varying levels of specificity and with varying terminologies, can be used to convey these relationships within the application. To foster greater efficiency, data should be collected once, shared, and reused for many different purposes. Clinical care, decision support, research, and patient safety initiatives all rely on the same collected data.
The accurate exchange of electronic patient data plays a key role in providing quality healthcare. The ability to produce on-target and reliable research and analysis using standardized clinical terminologies is essential to supporting the exchange of data to truly compare patient care outcomes on both a national and international scale.
— Cynthia B. Lundberg, RN, BSN, is a clinical informatics educator with SNOMED Terminology Solutions (STS), a division of the College of American Pathologists. Before joining STS in 2006, Lundberg devoted 14 years to designing, implementing, maintaining, and collaborating on nursing terminology in hospital systems.
SNOMED, SNOMED CT, and IHTSDO are trademarks of the International Health Terminology Standards Development Organisation. All other trademarks used in this document are the property of their respective owners.