Standardized Terminology Within the Electronic Health Record

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Standardized Terminology Within the Electronic Health Record

Patient data is one of the most important aspects of healthcare. Nowadays, the number of different methods of diagnosis and treatment in healthcare has increased significantly. The amounts of information about the patients health, prescribed medications, laboratory test results, and other necessary indicators, which must be memorized and processed by the doctor, are constantly growing. In addition, data on the patients health status is most likely dispersed across several medical institutions providing medical care. Lehne et al. (2019) add that most of todays medical data lack interoperability: hidden in isolated databases, incompatible systems and proprietary software, the data are difficult to exchange, analyze, and interpret (p. 1). All this information necessitates its electronic integration to ensure the best medical performance and patient outcomes. Thus, it becomes crucial to design an electronic health record system and provide specific standards for it to successfully operate the arrays of medical data.

Standardized terminology in healthcare records refers to the establishment of a unified taxonomy that would be applied to the electronic health records of an institution. Such taxonomy would be shared among all users of the system, offering them equal opportunities to use it. There are many advantages to the use of this approach: first of all, it erases the possibility of misinterpretation and misunderstanding among the institution workers while facilitating efficient communication. For example, Caudle et al. (2017) proposed standardized pharmacogenetic terms that will improve the understanding and interpretation of pharmacogenetic tests and reduce confusion by maintaining consistent nomenclature (p. 215). Moreover, it also establishes care standards that can be easily followed by all employees due to the use of common language and terms. Finally, the managing lead can evaluate the efficiency of care through unified measurement tools and offer the employees a clear review of their work.

However, the disadvantages of such a system should also be taken into account: for example, standardized terminology would allow less flexibility in terms of assessing patients condition. With only common terms in practice, healthcare workers would need to seek ways to describe specific conditions of the patients and put effort into adjusting the terms. Another important issue is not directly related to the standardized terminology itself rather, it is a general problem of all electronic health record systems: the maintenance costs and difficulty. Cowie et al. (2017) state that concerns have been raised about the increasing recruitment challenges in trials, burdensome and obtrusive data collection, and uncertain generalizability of the results (p. 1). Complex EHR systems with massive amounts of data require significant monetary and human resource input to support their operation.

Looking at the topic of standardized terminology in HER systems from the perspective of patient care outlines similar advantages to it. First of all, the patient information stored in standard terms can be easily transferred to other healthcare facilities, and the doctors and nurses there would not have issues deciphering it. This facilitates continuity of care, and the patient receives further treatment in a timely manner. Additionally, this strategy also offers a more individualized approach to patient care by providing more clear terminology. According to Madsen et al. (2017), standardization and precision in the use of sex and gender terminology will lead to a greater understanding and appropriate translation of sex and gender evidence to patient care (p. 122). The main disadvantage here is the issue with data safety: constant transferring of data to other clinics might result in malware problems, loss of information, or misuse of it.

Understanding how electronic health record systems work is crucial for real-life practice, as any healthcare professional is required to use them in their practice environment. Reviewing the advantages and disadvantages of standardized terminology in EHR systems allows one to recognize its specific features and goals, as well as account for potential issues. Moreover, by looking at the problem from the perspective of patient care, a nurse can learn how to use this standardized taxonomy more efficiently and avoid data losses in the process.

References

Caudle, K. E., Dunnenberger, H. M., Freimuth, R. R., Peterson, J. F., Burlison, J. D., Whirl-Carrillo, M., Scott, S. A., Rehm, H. L., Williams, M. S., Klein, T. E., Relling, M. V., & Hoffman, J. M. (2017). Standardizing terms for clinical pharmacogenetic test results: Consensus terms from the Clinical pharmacogenetics implementation consortium (CPIC). Genetics in Medicine, 19(2), 215223. Web.

Cowie, M. R., Blomster, J. I., Curtis, L. H., Duclaux, S., Ford, I., Fritz, F., Goldman, S., Janmohamed, S., Kreuzer, J., Leenay, M., Michel, A., Ong, S., Pell, J. P., Southworth, M. R., Stough, W. G., Thoenes, M., Zannad, F., & Zalewski, A. (2017). Electronic health records to facilitate clinical research. Clinical Research in Cardiology, 106(1), 19. Web.

Lehne, M., Sass, J., Essenwanger, A., Schepers, J., & Thun, S. (2019). Why digital medicine depends on interoperability. Npj Digital Medicine, 2(1). Web.

Madsen, T. E., Bourjeily, G., Hasnain, M., Jenkins, M., Morrison, M. F., Sandberg, K., Tong, I. L., Trott, J., Werbinski, J. L., & McGregor, A. J. (2017). Sex- and gender-based medicine: The need for precise terminology. Gender and the Genome, 1(3), 122128. Web.

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