Medical research for treatment and other medical drug development faces overwhelming challenges in information management and recording requirements, even though the efforts have become increasingly global in scope. Required standards for the design and coding of assessment data can aid in ensuring the utility, quality, reuse, and acceptance of assessment outcomes (Truran et al., 2010). These standards further permit the emergence of compatible and recyclable software for coding and exchange of search information. Furthermore, the standards allow regularly replacing paper-based systems and tedious, error-prone manual coding techniques.
For a significant period, the Study Data Tabulation Model (SDTM) has redesigned the standard structure for submitting study information. Consequently, by 2004, the Clinical Data Interchange Standards Consortium (CDISC) had recognized controlled terminology as an essential focus for its efforts to back an extend SDTM (Truran et al., 2010). Controlled terminology is necessary to realize computable semantic, exchanging data reliably amongst systems, and consistently representing what the information means so the users can appreciate it. This paper aims to analyze controlled terminology and standards in healthcare and their role in achieving technological interoperability.
The advantages of controlled systems in healthcare terms overwhelm the significant efforts to address unstructured information and interoperability. Various national programs share the objective of standardizing terminologies within EHRs to expedite data transmission, knowledge, and communication between systems with the overall goal of interoperability (Norman-Marzella, 2016). Meaningful utilization is among the core missions of interoperability with the intentions centered on priorities to enhance safety, quality, effectiveness, public healthcare and population, and minimizing health gaps. Identifying a method to overcome the variability of medical data is displayed, which is vital in interoperability and enormous data. Despite all the clinical information in EHRs, databases, and records stores that can be employed in research and community health, practitioners are incapable of extrapolating them owed to the absence of homogenous terminologies.
Physicians, medical practitioners, and other clinical experts face various challenges when recording their research and diagnoses with related primary care specialists and specialists’ offices. These challenges have been instigated by the guidelines located in EHRs from standardized coding systems comprising ICD-10, CPT, LOINIC, and ICD-9 (Kuperman et al., 2010). Primary care specialists are usually compelled to link tests and processes with conditions or diagnoses that the patient does not display.
For instance, when an individual complained of lower backaches and on further analysis and diagnostic CT, it was identified that the patient had symptoms of a rare illness named epiploic appendagitis. When the primary specialist was compelled to select from a list of ICD-9 programs to relate the CT diagnosis the nurse conducted, there was no select for epiploic appendagitis. Hence, the provider opted for the next suitable option, diverticulitis (Kuperman et al., 2010). These two occasions are not comparable and display various barriers healthcare nurses undergo when selecting from a category of homogeneous terminologies in an EHR.
Another challenge that primary care doctors convey is the quantity of effort placed towards pursuing the appropriate analysis from a category of homogeneous terminologies since it eliminates one-on-one meetings with consumers. The impediment backed by standardization is generally centered because the nursing practice is immensely intricate and ever-transforming. Consequently, it is difficult to deduce a homogeneous catalogue of terminologies that satisfies the primary physicians’ and specialists’ needs (Hovenga, 2010). The disparity in vocabulary found in distinct EHRs further presents a significant challenge to interoperability. Consequently, the one-on-one diagnosis usually effective in making the correct diagnosis is limited by such standards.
In conclusion, interoperability and standardization play a significant role in the success of the national and the overall healthcare industry. With the continued federal programs and ongoing development and collaboration of standard medical terminologies in both medicine and nursing, the effectiveness of interoperability and standardization is therefore unchallenged. Therefore, stakeholders should train primary care physicians and specialists to use the systems to share patient information appropriately. Furthermore, improvements should be made to the EHRs systems to accommodate all dialysis to enhance treatment outcomes.
References
Hovenga, E. J. (2010). 11. National Standards in Health Informatics. Health Informatics: An Overview, 151, 133.
Kuperman, G. J., Blair, J. S., Franck, R. A., Devaraj, S., Low, A. F., & Group, N. T. I. C. S. C. W. (2010). Developing data content specifications for the nationwide health information network trial implementations. Journal of the American Medical Informatics Association, 17(1), 6–12. Web.
Norman-Marzella, N. (2016). EHR Technology: Improvement review of a small rural hospital. Journal of Health Science, 4, 277–282. Web.
Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37–39. Web.