Week 1 Blog Assignment/STANDARDIZED NURSING LANGUAGE and INFORMATICS, THE LANGUAGE OF NURSING.

 SNOMED-CT

In an effort to promote the uptake of electronic health records, (EHR) as a way to promote patient safety and the delivery of quality care, the clinical terminology SNOMED CT or the systematized Nomenclature of Medicine Clinical Terminology has been deployed.  SNOMED was created by the College of American Pathologists and later transferred ownership to the International Health Terminology Standards Development Organization (IHTSDO) (Lusignan, 2011). The SNOMED CT describes clinical entities such as diseases, substances and organisms through clinical terminology. It facilities what the provider inputs into the EHR. With the use of SNOMED CT, used as the national standard clinical  terminology in Australia, there should be a significant change in the predictability of the clinical records and data reliability adding consistency to documentation. This will help to reduce miscommunication and inefficiencies that effect throughput and timeliness (Truran, 2010) . The EHR will contain standardized terminology describing the clinical information. This language or clinical reporting is acknowledged internationally and is now an NHS standard in England.

           INFORMATION MANAGEMENT                                       DATA STANDARD

SNOMED CT is comprehensive and makes searching for codes difficult and time consuming. One way to make this more efficient is to have a certain number of codes available for each specialty so that there is a smaller list to go through. practitioners are rewarded for reaching indicator targets, in the UK through the pay for performance  system that is in place. Using a smaller list may tinge the data, but if providers want to get paid they have to stay within the list of codes assigned. The training of non clinical staff in this system is overwhelming and not realistic. There needs to be new cost analysis' done and the pros and the cons of implementation need to be compared (Lusignan,  2011).
                                              

LOINC

Semantic interoperability is the ability for one IT system to receive information from another and then make it compatible to its business principles and make the information compatible and usable The Center for IT Leadership believes that introducing semantic inoperability and implementing it would produce the greatest economic benefit to the US health system ( Dixon, 2015). The Logical Observation Identifiers Names and Codes (LOINC), which has been in development for 20 years, provides universal identifiers for laboratory tests.

For an EHR to be certified as meaningful use, the LOINC and SNOMED CT are required for communicating tests. The translation process or mapping  is a set of terminology mediation strategies used among health enterprises ( Dixon, 2015). Identifying the correct concept from standard vocabulary is difficult for even the personnel with a good understanding of the tests when they lack the specific knowledge of their local concepts to standard vocabularies.

National policies in the US that require the use of LOINC contribute to the pressure on organizations to map quickly and efficiently. To do this there is software out now that shows how many times a LOINC has been mapped to local codes of other organizations and use it as a comparison as a match. Mapping to standard vocabulary is important to semantic inoperability. It is also time consuming and costly to an organization. The goal is to enable semantic inoperability through the promotion of the software tool as a sourced repository of mappings for use by organizations (Dixon, 2015).

                                                                     

                                                                                






Resources:

de Lusignan, S., Chan, T., & Jones, S. (2011). Large complex terminologies: more coding choice, but harder to find data- reflections on introduction of SNOMED CT (Systemized Nomenclature of Medicine- Clinical Terms) as an NHS standard. Informatics in Primary Care, 19, pp. 3-5.

Dixon, B. E., Hook, J., & Vreeman, D. J. (2015, Spring). Learning from the crowd in terminology mapping: the LOINC experience. Lab Medicine, 46(2), pp. 168-174.

Retrieved on February 1, 2016 from https://www.google.com/search?q=LOINC&biw=2477&bih=1365&tbm=isch&source=lnms&sa=X&ved=0ahUKEwiFxIjgldjKAhWDOhoKHUXxBpIQ_AUICCgD&dpr=0.75#imgrc=KD16KcXqGyeN2M%3A

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).