NURS 8210: Transforming Nursing and Healthcare Through Technology | Week 3

Efficient, reliable, and interoperable information systems rely on consistent terminology and standards. Since the mid-1960s, the health care industry has attempted to align its codes and terminologies. This task has been challenging, however, because the myriad of clinical systems—from patient diagnosis to surgery—use terms and procedures that vary widely. As technology continues to develop and the health care industry progresses, organizations need to come together to achieve the complex goal of code compliance. NURS 8210:Week 3: Controlled Terminology and Standards Paper

This week, you examine IT standards and terminologies, and consider the critical role they play in achieving technology interoperability.

Learning Objectives

Students will:

• Evaluate the challenges of sharing data across information systems
• Propose solutions for interoperability challenges

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings – NURS 8210:Week 3: Controlled Terminology and Standards Paper

Course Text: Ball, M. J., Douglas, J. V., Hinton Walker, P., DuLong, D., Gugerty, B., Hannah, K. J., . . . Troseth, M. R. (Eds.) (2011). Nursing informatics: Where technology and caring meet (4th ed.). London, England: Springer-Verlag.

• Chapter 13, “Standards and Interoperability

This chapter introduces the definition, standards, and challenges of interoperability. The authors also detail the impact that interoperable systems will likely have on the future of electronic health records (EHRs) in response to the national health IT agenda.

Course Text: American Nurses Association. (2008). Nursing informatics: Scope and standards of practice. Silver Spring, MD: Author.

• Trends in Care Delivery Models and Innovation” (pp. 63-66)

This excerpt gives examples of projects that are being used to accelerate informatics implementations in organizations.

Grain, H. (2010). Clinical terminology. Studies in Health Technology and Informatics, 151, 70-83.

This article begins with an historical overview of computer use in the health care industry. Then it takes an in-depth look at the incentives being used to increase the percentage of practice settings that comply with the integration of electronic health records and interoperable technologies.

Hovenga, E. J. (2010). National standards in health informatics. Studies in Health Technology and Informatics, 151, 133-155.

This article provides an in-depth review of the development of national standards. It includes a look at the components of standards and how they affect the interoperability of systems.

Kuperman, G. J., Blair, J. S., Franck, R. A., Devaraj, S., & Low, A. F. H. (2010). Developing data content specifications for the Nationwide Health Information Network Trial Implementations. Journal of the American Medical Informatics Association, 17(1), 6-12.

The authors of this article use the experiences of the Nationwide Health Information Network’s Trial Implementations project to describe the process and challenges of developing content specific standards.

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.

Real-world examples are used in this article to predict how the management of health information will change as standardized terminologies are implemented within practice settings.

American Nurses Association (2006). ANA recognized terminologies and data element sets.

By navigating through this website, you can see the table that shows the data sets recognized by the American Nurses Association.

Centers for Disease Control and Prevention. (2009). Health data standards.

This website provides a link to two organizations that focus on health standards and statistics. The first organization that you may choose to view is the National Committee on Vital and Health Statistics, which was established by Congress and advises the Department of Health and Human Services. The second is called the Public Health Data and Standards consortium, a not-for-profit organization that works with a variety of agencies, associations, and organizations.

Logical Observation Identifiers Names and Codes (LOINC®). (2011).

Access this website to gain information on LOINC’s universal coding system for laboratory and clinical observations.

Saba, V. (2011). Clinical Care Classification System.

At this website, you can view the framework of the Clinical Care Classification (CCC) coding structure. Use the side tabs to view the features that make this coding terminology widely accepted as a means to document patient care in electronic health care records.

U.S. National Library of Medicine. (2011). Unified Medical Language System® (UMLS®).

The Unified Medical Language System uses its three tools, or Knowledge Sources, named Metathesaurus, Semantic Network, and SPECIALIST Lexicon and Lexical Tools to combine many popular standards and terminologies used in the health care industry. This integrated system facilitates interoperability between computer systems.

Required Media

Laureate Education, Inc. (Executive Producer). (2011). Transforming nursing and healthcare through technology: The standardized representation of health information. Baltimore, MD: Author.

Note: The approximate length of this media piece is 16 minutes.

This week’s media presentation introduces the importance of standardized data in interoperable systems.

Optional Resources

ABC Coding Solutions. (2018). Retrieved from https://abccodes.com/

Discussion: Welcome to the Week 3 Discussion area!

Post your responses to the Discussion based on the course requirements.

Your Discussion postings should be written in standard edited English and follow APA guidelines as closely as possible given the constraints of the online platform. Be sure to support your work with specific citations from this week’s Learning Resources and additional scholarly sources as appropriate. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct. Initial postings must be 250–350 words (not including references). NURS 8210:Week 3: Controlled Terminology and Standards Paper

ADDITIONAL INFORMATION 

Controlled Terminology and Standards

Introduction

Controlled terminology is the use of language that has been approved by an organization for a specific purpose. It’s used to ensure accurate communication, avoid confusion, and promote organizational goals. Controlled terminology can be used in any type of written or oral communication for any audience—from employees working together on projects to doctors discussing medical procedures with patients.

What is Controlled Terminology?

A controlled vocabulary is a set of terms that are used to describe a topic. For example, the term “frozen foods” is used to describe any food that has been frozen. This term was chosen because it describes an attribute of the food without any unnecessary human-created words in it—it’s simple and easy to understand by anyone who’s ever had their freezer break down or been too lazy to go out and buy groceries on time (or both).

This type of controlled terminology can be used for many different things, including:

• Controlled vocabularies describing media files (such as audio tracks and video clips)

• Controlled vocabularies describing computer programs

CTSI and HHS Standards

CTSI is a joint venture of the American National Standards Institute (ANSI) and the U.S. Department of Health and Human Services (HHS). CTSI publishes standards that are developed by ANSI technical committees, approved by ANSI, and adopted by HHS.

The following sections provide information about these standards:

Standards from other Organizations

Another important consideration is that standards from other organizations are not always the same as CTSI and HHS standards. In some cases, standards from other organizations may be more or less stringent than CTSI and HHS.

Takeaway:

• Takeaway:

• The CTSI and HHS Standards are the main standards that you should be familiar with.

• Other organizations have their own standards as well, but these are the most important ones to know about.

Conclusion

We hope this blog post has helped you to understand the role of Controlled Terminology Standards and why they’re so important. We promise that we won’t judge your puns, though.