Electronic Health Record Systems

Question: Discuss about the Electronic Health Record Systems and Standard Vocabularies. Answer: Introduction The introduction and adoption of information technology have led to the development of electronic health records that have vastly improved the administration of medical care in the recent years making it crucial in the medical world. Electronic health records could be described in non-technical language as an electronic rendition of a patients restorative history. However, its success envisioned by its incorporation of standardized vocabularies, that increased interdepartmental communication while offering medical care to the patient. The Standard medical vocabularies, wordings, or coding frameworks are organized rundown of terms, which together with their definitions intended to portray the healthcare administration of patients unambiguously. These vocabularies cover diseases, prescription of drugs and medication and so on. They are utilized to bolster recording and divulge a patient's care at different levels of detail, through the electronic health records (EHRS) Tastan, (2014) Rationale of standard vocabularies in electronic health records (EHRS) Electronic health records systems are the following stride in the progress of medicinal services that can fortify the connection amongst patients and medical practitioners. The information, readiness and accessibility of it will empower these practitioners to settle on better choices and give better care. Moorhead,(2014). Like in such a scenario where data in numerous areas is to forage, shared, and incorporated whenever required there will require normal vocabularies for the individual, clinical, and general health data allowing the individual to be satisfied with the information received. Other reasons for incorporating standardized terminologies include: 1.Accessing and acquiring of coded information utilizing numerous properties and at various levels of specificity than initially coded 2.Provide medical practitioners with decision support while offering treatment, e.g., drug prescription increasing shared understanding throughout the field Reviewing the nature of administration and benchmarking while Supporting examination exercises 1.Organizing information section with adaptability of expressionfledgling to expertise Examples of vocabularies or terminologies: 1.ABC Codes 2.Clinical Care Classification (CCC), 3.International Classification of Nursing Practice (ICNP), 4.Logical Observation Identifiers Names and Codes (LOINC), 5.NANDA International 6.Nursing Minimum Data Set (NMDS), 7.Nursing Outcomes Classification (NOC), 8.Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT), Issues associated with EHRs design and solutions. A few frameworks that focus on implementing fine-grained essential clinical information have been restrictive, constrained, troublesome for clinicians to utilize and come around leading to low client acknowledgment. This issue is addressed by creating training programs for the medical practitioners where they can be taught how to use the systems. Additionally, research could be undertaken based on questionnaires on how the medical practitioners would want the systems tailored to their advantages Nelson and Staggers, (2017). Semantic EHRs underpinning-The incorporation of vocabularies or terminologies in most EHRs lack a semantic underpinning which could lead to misdiagnoses or confusion. This problem could be solved by updating systems and adding description logic encoded systems e.g. SNOMED CT.' Existing medicinal vocabularies change in their scope and fulfillment. This issue could be solved by undertaking and investing in medical research Complete clinical phrasing frameworks are expected to assist incorporate patient information with EHRs. By use of SNOMED CT expects to help structure and modernize the medicinal record yet should be utilized effectively and reliably to protect information quality and boost shareability. Ajami, and Bagheri-Tadi,(2013). Lack of a single standard and comprehensive vocabularies which would improve the flow of medical information which could prove fruitful later .this could be addressed by increased research and invest Paganin and Rabelo ,(2013). Reference Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., ... Wilkie, D. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review.International journal of nursing studies,51(8), 1160-1170. Nelson, R., Staggers, N. (2017).Health informatics: An interprofessional approach. Elsevier Health Sciences. seng, H., Moorhead, S. (2014, July). The use of standardized terminology to represent nursing knowledge: nursing interventions relevant to safety for patients with cancer. InNursing Informatics(Vol. 201, pp. 298-333). Paganin, A., Rabelo, E. R. (2013). Clinical validation of the nursing diagnoses of impaired tissue integrity and impaired skin integrity in patients subjected to cardiac catheterization.Journal of advanced nursing,69(6), 1338-1345. Ajami, S., Bagheri-Tadi, T. (2013). Barriers for adopting electronic health records (EHRs) by physicians.Acta Informatica Medica,21(2), 129.