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NURS 8210 Week 3 Controlled Terminology and Standards ANSWER

NURS 8210 Week 3 Controlled Terminology and Standards

By Day 3 post a cohesive response that addresses the following:

  • Evaluate the challenges that health care organizations may face when sharing data across systems.
  • Using your professional experience and/or information gathered through research, provide at least two specific examples of interoperability challenges.
  • Propose at least two strategies a health care organization might implement to address interoperability challenges.

Read a selection of your colleagues’ postings.

NURS 8210: Transforming Nursing and Healthcare Through Technology

INITIAL POST

Controlled Terminology and Standards

The rewards of all the efforts placed by the government under the HITECH Act to encourage usage of electronic health record (EHR) systems among providers by the year 2014 did not last too long before we started realizing that the health care system is in crisis. According to the Agency of Healthcare Research and Quality (AHRQ), this crisis due to high cost, medical errors, poor coordination, and administrative inefficiency, which according to the Agency of Healthcare Research and Quality (AHRQ), is connected to the failure to incorporate health IT into our healthcare system (Ball et al., 2011, p. 207). So, how do we incorporate health IT into the healthcare system when in the first system computer uses numeric or alpha-numeric codes and in the second system human communications with words? Even within the health care system, those words have so many synonyms, and when we succeed to think about coding those words, it is still not universal, and we end up with so many terminologies, classifications, or codes such as ICD-10, SNOM

NURS 8210 Week 3 Controlled Terminology and Standards ANSWER
NURS 8210 Week 3 Controlled Terminology and Standards ANSWER

ED-CT, LOINC, ICNP, CPT, ICD-10-CM, MeSH, RxNorm, etc. Therefore, is an urgency to adopt health information technology (IT) interoperability standards. In this Discussion, we evaluate the interoperability and coding challenges faced by healthcare organizations and provide some examples of interoperability challenges and strategies to overcome them.

Evaluating the Interoperability and Coding Challenges

The challenges that health care organizations may face when sharing data across systems is the lack of a universal language, unlike science which has one single language, allowing scientists to communicate with one another worldwide. In the Laureate Education, Inc. (2011) video, Dr. Stuart talked about how in medicine, sets of classifications such as diagnosis and disease are often described as an art more than a science, with different professional groups developing different ways of describing the same thing (Ad-hoc classification), from where the necessity to have a standard classification to share data across systems. We also have the formal standards approved by the government and some international organizations and the informal standards developed and approved by a small group of professionals.

Examples of Interoperability Challenges

According to Iroju et al. (2013), some example interoperability challenges include the complexity of the healthcare domain, standardization problems, use of incompatible clinical ontologies/terminologies, legacy systems, and resistance to change. According to these authors,

  • The complexity of healthcare is due to many actors such as doctors, radiologists, nurses, pharmacists, laboratory technicians collaborating to treat the patients, and who generate complex information with different types of data such as patient administration, organizational information, clinical data, and laboratory/pathology data.
  • Standardization problem is due to lack of uniformity or standardization in the nursing assessment process during patient admission to the hospital, with serious error omission in this process leading to the possible untimely death of a patient. Multiple standards used in healthcare with multiple standards breed confusion, demonstrating the absence of uniformity or standardization of the basic means of communication.
  • Legacy systems (mostly with EMR) built before introducing common national standards have limited interoperability and are designed for a particular task or facility (Iroju et al., 2013).

Strategies to Address those Interoperability Challenges

According to Iroju et al. (2013), strategies to address those interoperability challenges include adoption of standardized terminology, a connection of legacy systems to health networks, teaching healthcare providers how to use the Information and Communication Technologies (ICTs) tools in healthcare and their importance, consider privacy and security policies when designing the interoperable healthcare system, and develop/design the technologies at the level of human-computer interaction (user interface) to facilitate caregivers successful use of ICTs.

 

Reference

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.). Springer-Verlag

Iroju, O., Soriyan, A., Gambo, I., & Olaleke, J. (2013). Interoperability in healthcare: Benefits, challenges, and resolutions. International Journal of Innovation and Applied Studies, 3(1), 262-270.

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

U.S. Department of Health & Human Services [HHS] (2017). HITECH Act Enforcement Interim Final Rule. https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html

The availability of data across systems has undoubtably transitioned healthcare in the 20th century. Ease in availability, communication, patient access to records and uniformity are just a few benefit advances that informatics provides. Sharing data across systems can present challenges. While working in inpatient psychiatry I have personally witnessed patient concern for “this information in my chart.” As health care professionals, we are not immune to mental health and physical challenges. While treating members in our health care system for mental health related issues the fear of judgment and embarrassment is often identified. The concern of maintaining HIPPA with the ease and accessibility can contribute to patients feeling uneasy and potentially guarded in information recall.

Additional experiences I have encountered as a challenge specifically to interoperability communication is resistance to change. Resistance to change is not uncommon to encounter initially however with exposure and time the initial fears can be resolved. The uniformization of hand offs in care with intraoperative communication can be intimidating to individuals with a lower comfort level in computerized records and charting. Comfort levels in computer technology and programing can present a significant obstacle to interoperability in our health care system worldwide.
A strategical approach to accommodating the protentional fear during hand off reposts can be alleviated by the utilization of primary interoperative care. According to Dexter, et al., (2019) intraoperative care provides multiple opportunities for a different provider to assume responsibility for the patients between cases, thus avoiding an official face to face handoff altogether. Providing learning opportunities in skill labs, hands on training and resources readily available can also assist in identifying and managing challenges associated with intraoperative communication and advances throughout healthcare.

References

Basa, S. (2017). Intraoperative challenges and management strategies in orthognathic surgery. International Journal of Oral  & Maxillofacial Surgery46, 8.

Dexter F, Osman BM, & Epstein RH. (2019). Improving intraoperative handoffs for ambulatory anesthesia: challenges and solutions for the anesthesiologist. Local and Regional Anesthesia, volume 12, 37–46.

Grain, H., (2010) Clinical Technology. International Journal of Oral & Maxillofacial Surgery46, 8.

 

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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed
  • Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
  • Here are some helpful links
  • Student paper example
  • Citing Sources
  • The Writing Center is a great resource