We talked previously about Why Standardized Terminology is Important and now we’ll talk about what Standardized Terminology in Healthcare really means for public health agencies, and their clients.
Standardized terminology facilitates interoperability.
Interoperability, at least in terms of healthcare, describes the ability of health information systems to work together, within and across agency borders, to create an Electronic Health Record (EHR).
However, interoperability is not just found in healthcare, but everywhere in the outside world.
Some examples include:
Phones – a phone can make and receive a phone call from any other phone, in any country, whether it’s a traditional landline or the latest wireless smartphone.
Electrical items – everything from domestic consumer goods to industrial equipment is designed to have the same plug to fit into standard plug sockets
Web browsers – web browsers support HTML standards so that a web page will display as intended on standard and 3rd-party browsers on a Windows PC and Mac, as well as tablets and smartphones, anywhere in the world.
In order for systems to be compatible and be able to talk to each other, they rely on standards, which provide the rules and guidelines.
These rules include things like:
- The size and shape of a plug and socket
- How data is transmitted and received
- The format in which data is displayed
In healthcare, like in many other areas, these rules and guidelines are subject to a meticulous review process before they can be used in Electronic Health Records.
Federal initiatives, such as ARRA as well as many state and local requirements increasingly demand that EHR systems are interoperable with other systems.
“We are really trying very hard to stay in alignment with national requirements for the standardization of data and information exchange, so we are definitely sticking with the Omaha System and Nightingale Notes.”
If you’re a public health agency in the process of choosing a new EHR system, then you need to know that it is capable of communicating with state systems such as immunization registries and HIEs so that your agency can share data with the state and other health departments.
In terms of healthcare, this means that client information only needs to be entered into a system once, and that client data can be made available to caregivers where and when they need it.
Standardized terminology ensures that systems can talk to each other, but it also means that people can talk to each other too and mean the same thing.
- Healthcare professionals in different departments or locations may use different words, terms or language to describe client conditions, or care options.
Think about this:
- Somebody who goes to the doctor regularly, might say they are ‘not feeling very well’
- Which could mean they just have a bad cold
- Somebody who never goes to the doctor, might say they are ‘not feeling very well’
- Wnd have a serious medical condition
- Somebody with a long term medical condition such as arthritis or cancer, might say they are ‘not feeling very well’
- But have been bedridden for days but don’t like to cause a fuss
What does something like ’generally healthy’ mean when describing a client?
- It’s likely to mean different things to different people in different public health agencies and different locations
This means it’s hard to compare like with like, or see what treatments have proved successful, or determine demographics.
Having a standardized terminology means using the same terms to describe the same things such as:
- Medical conditions
- Client health
- Intervention success
Ensuring that there are standards when it comes to talking about conditions or types of clients, makes it much easier for all involved which leads to improved communication.
Now can you see how improved communication leads to improved care?
Shared data can be extremely useful as it enables agencies to see what they can learn from other agencies.
Perhaps another agency:
- Treats the same type of clients
- Has similar demographics
- Has common issues
Standardized terminology means that data from other systems can be combined, and the accuracy and relevancy of the data can be assured.
Knowing how agencies have tackled issues previously or what can be learnt from their experiences means that finding the answers can be much quicker, as the appropriate solution may already be in place in another agency. This obviously benefits clients, and saves time and money.
“The payoff for us with having an EHR built on the Omaha System and having that adopted by Southern Prairie Community Care, which is our ACO, is that we really can exchange data with other ACO members.
“We have a very fluid population in southwest Minnesota. Being able to have that continuity of care when clients move from one place to another, to be able to achieve The Triple Aim (improved population health, improved healthcare quality & experience, reduced per capita cost of healthcare) for the clients we serve, in addition to being able to monitor our own data and measure our own outcomes, is the end result we all desired.
“Nightingale Notes has allowed us to get in the sandbox and play with the other deliverers of healthcare: the clinics, hospitals, mental health facilities; they are all integral.”
Evidence-based research and practice becomes much more valuable when professionals can describe the same healthcare needs and conditions using the exact same language.
Could you imagine how much more difficult this would be with paper forms and charts?
Shared pathways may be a new term for you.
Put simply, pathways are standardized plans of care that define and reinforce best practices.
They are usually defined for a specific client population, such as children with special needs, or mothers with newborns, and designed to ensure that appropriate interventions are identified and performed.
Standardized terminology means that pathways can be shared across agencies, and so can be used to demonstrate that certain processes work, promote the best way to provide client care, and support the client, public health nurse and the administration. They can also help save time and save money too.
“Nightingale Notes has allowed us to get in the sandbox and play with the other deliverers of healthcare: the clinics, hospitals, mental health facilities.”
Shared pathways mean that agencies facing similar issues can quickly see if the problem has already been solved.
Ability to evaluate
Standardized terminology also means that reporting is much more beneficial.
Being able to see client outcomes, and compare them to other clients, agencies and locations enables agencies to see what works, and why.
“We are able to get reports from Nightingale Notes that we can use as QI tools. We are able to see where we have missing data and where people aren’t accurately using the documentation standards we’ve developed.
Every time we run a report, it gives us the tools we need to adjust our documentation to ensure it reflects what we are really doing.”
In addition, it’s also much easier to explain a course of action or why a certain shared pathway is the right choice to someone with:
- No medical training
- No knowledge of treatments, or
- No understanding of expected outcomes
Standardized Terminology leads to better visibility.
Showing the value of the work done by community health professionals other than physicians can be difficult. To those looking to impress on policy makers or funding sources, being able to share success stories is vital.
“One crucial benefit we didn’t have before using the Omaha System was the ability to use inter-professional teamwork to get a fuller picture.
Our epidemiologists are our data experts; they extract the data from our EHR, Nightingale Notes, but the nurses and social workers are the experts in practice and can help give the full picture.”
Standardized terminology provides a ‘common vocabulary’, and a clear and precise way to demonstrate how well the client(s), agency, or other metrics like demographics, or location is performing.
So why Nightingale Notes?
Nightingale Notes EHR from Champ Software uses the internationally used Omaha System, which will be familiar to many healthcare professionals.
If you’re not sure what the Omaha System is, or the benefits, then the Omaha System Overview is a good place to start.
Then learn more about what the Omaha System offers you.
We have built Nightingale Notes on top of the Omaha System, which means that it can use the full capability of the Omaha System.
Don’t just take our word for it
Although we’re bound to be biased, we think our Nightingale Notes EHR is the right choice for many public health clinics like yours across the country.
Here’s just two more reasons why:
“Nightingale Notes and the Omaha System have allowed us to develop dashboards to provide to our board to show measurements: where are we with the clients we serve, what kind of improvements are we seeing, what kind of services are we providing, what kinds of increases are we seeing in the needs of the clients we serve.”
“We are able to view our outcome data because we have an EHR, Nightingale Notes, that is based on the Omaha System. So we have the outcome rating scale to look at.
We can accurately describe our population: number, age, ethnicity, education, poverty level, etc. This gives us a good picture of who we’re serving.
We can also accurately describe our services. We can determine the frequency of problems, which are our most common problems, and where we place our major focus.”
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.
If you’re ready to see how Nightingale Notes can help you, Contact Us at (507) 388-4141 today, and tell us what you need.
We’re looking forward to hearing from you.