What does Standardized Terminology in Healthcare really mean?

What does Standardized Terminology in Healthcare really mean?

We talked previously about Why Standardized Terminology is Important  and now we’ll talk about what it really means for public health agencies, and their clients.

Interoperability

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.”

Pat Stewart, PHN, Administrator/Director, Des Moines Valley Health and Human Services

A public health agency in the process of choosing a new EHR system needs to know that it is capable of communicating with state systems such as immunization registries and HIEs so that the 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.

Communication

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.

Having a standardized terminology means using the same terms to describe the same things such as medical conditions, client health or intervention success.

For somebody who never goes to the doctor, describing themselves as ‘not feeling very well’ could potentially mean they have quite a serious medical condition in their opinion, but in reality, might just mean they have a bad cold.

For someone with a long term medical condition such as arthritis or cancer, describing themselves as ‘not feeling very well’ might mean that they 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.

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.

It’s easy to see how improved communication leads to improved care.

Shared data

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, or 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.”

Pat Stewart, PHN, Administrator/Director, Des Moines Valley Health and Human Services

Evidence-based research and practice becomes much more valuable when professionals can describe the same healthcare needs and conditions using the exact same language.

Imagine how much more difficult this would be with paper forms and charts.

Shared pathways

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.”

Pat Stewart, PHN, Administrator/Director, Des Moines Valley Health and Human Services

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.”

Suzanne Plemmons, MN, RN, PHCNS-BC, Community Health Director, Kitsap Public Health District

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.

Better visibility

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.”

Suzanne Plemmons, MN, RN, PHCNS-BC, Community Health Director, Kitsap Public Health District

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 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.

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 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.”

Pat Stewart, PHN, Administrator/Director, Des Moines Valley Health and Human Services

“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.”

Suzanne Plemmons, MN, RN, PHCNS-BC, Community Health Director, Kitsap Public Health District

Next steps

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.

Download eBook

 

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.

By | 2017-12-15T23:29:59+00:00 October 31st, 2017|Standardized Terminology|0 Comments

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