Agencies are rushing to adopt EHRs to meet rapidly evolving federal, state, local, program, and grant mandates regarding electronic documentation.
In researching software options, you will find a key difference among them:
- Some are based on standardized terminologies while others are not
Read our recent articles which discuss what does standardized terminology in healthcare really mean, and what criteria should a standardized terminology meet.
If your program goals include the ability to measure client outcomes to clinician interventions in a reliable and valid way, you should consider purchasing software based on a standardized terminology.
A standardized terminology is simply a common language, nomenclature, classification, or taxonomy designed to be shared among users.
In health care settings, use of standardized terminologies is essential to clearly and accurately document client assessments, care, and outcomes.
If you cannot describe your care to others using a commonly understood language, then you cannot effectively:
- Establish standards
- Influence policy
- Expect funding for your programs
There are many benefits to using a standardized terminology, including:
- Meeting mandated interoperability requirements and standards
- Facilitating communication among nurses and other health care workers
- Enabling the collection of shared data to improve health care at the local level and beyond
- Adhering to standards of care and best practices, especially with the concurrent use of shared pathways
- Evaluating the effectiveness of community health care at all levels through measurement of outcomes
- Giving better visibility to your work
One example of an internationally-used standardized terminology is the Omaha System.
This standardized terminology is a leader among its peers in meeting the stringent criteria necessary for full integration and interoperability in electronic health records.
One of the first clinical nomenclatures to be developed, the Omaha System is a research-based and provides interoperability and communication across the continuum of community health: health clinicians, administrators, educators, and researchers.
The Omaha System is composed of three essential components to describe care:
- The Problem Classification Scheme (assessment)
- The Intervention Scheme (interventions/clinician actions)
- The Problem Rating Scale for Outcomes (measurement of outcomes).
You can read more about the Omaha System at www.omahasystem.org. You will find a valuable overview of the system, publications, FAQ’s, case studies, references, links, conferences, and the Omaha System Listserv.
Download our eBook, “Standardized Terminology for EHRs” to learn more about what criteria standardized terminology should meet so that you know what to look for when choosing a standardized terminology for your EHR.
Check out the references below for even more information about standardized terminologies and Omaha System users! You can also download our free ebook, Evaluating Standardized Terminology in EHR: Communicating What You Do.
- Martin KS. (2005). The Omaha System: A Key to Practice, Documentation, and Information Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press. http://www.healthconnectionspress.com/book2005.html
- Rutherford, M. (Jan 31, 2008) “Standardized Nursing Language: What Does It Mean for Nursing Practice?” OJIN: The Online Journal of Issues in Nursing. Vol 13 No. 1 http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/ vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.aspx
- Thede, L. (Aug 18, 2008) “The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves?” OJIN: The Online Journal of Issues in Nursing Vol 13 No. 3. http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/ElectronicHealthRecord.aspx
- Westra BL, Oancea C, Savik K, Marek KD. (2010, May/June). “The feasibility of integrating the Omaha System data across homecare agencies and vendors.” CIN: Computers, Informatics, Nursing, 28(3), 162-171. http://journals.lww.com/cinjournal/Abstract/2010/05000/The_Feasibility_of_Integrating_the_Omaha_System.9.aspx
- Zielstorff, R. (September 30, 1998). “Characteristics of a Good Nursing Nomenclature from an Informatics Perspective.” OJIN: The Online Journal of Issues in Nursing Vol 3 No. 2.