Archive for November 18th, 2011

Standardized Language in Healthcare

November 18, 2011

As the electronic health record (EHR) becomes increasingly utilized across the nation, a standardized language will need to be implemented and followed. This will improve more accurate billing, informed patient management, increased precision of documentation, and improve knowledge. Functioning without standards would be chaotic, out of control, and confusing to all individuals. Standardization proves to enhance any process. With the strategic organizational initiatives of many physician offices, clinics, medical centers, and hospitals to implement an automated electronic environment for documenting a patient’s health history, which then automate other processes, the need increases for the uniformity of a language. The downside of the uncontrolled terminology of medicine has been accentuated by the computer age, because without standard vocabulary the ability to acquire knowledge about healing professions through information technology is limited. Many clinical applications available today have restricted utility because they cannot understand each other. It seems with the urgency of healthcare facilities implementing EMRs, the development of a standard language is critical and needs to be on a fast track to develop solutions. Healthcare information system developers are not waiting for the standards bodies, in existence today, to make these determinations. These developers know that precise medical words are needed to analyze the information from automated medical records, which will improve quality and service in healthcare. Rather than use any existing clinical vocabulary standard, they are creating their own dictionaries or vocabulary sets. Although this represents a slight improvement over un-encoded or free text documentation, each vendor working in isolation, are creating a terminology which cannot be read or understood by other systems. This makes the potential of data exchange and comparing impossible. It is imperative that healthcare organizations, vendors, and government agencies work collaboratively to implement measures to effectively localize, update, and disseminate healthcare terminologies, mappings, and other terminology-related content currently issued by national and international standards bodies. A standardized language in healthcare is something of a monumental task, but one that needs dedicated professionals in establishing these standards. Although some standard languages exist, developed by various standards organizations, the need is paramount of unifying a standardized language. Controlled medical terminology is essential to maximize the true benefits of implementing a fully operational EMR. Additionally, if all physicians, nurses, patients, hospitals, clinics, payers, and government agencies would commit to the same healthcare language, the one who unquestionably benefits from this is the patient who can be any one of us.

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