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When it comes to Electronic health records explain the statement that interoperability is not possible without standards.

Others beside the UT students are very welcome to join in our conversation

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UTGE1-LR

For example, a set medical terminology and medical acronyms are used in the electronic healthcare records to facilitate understanding of a patient's health across multiple systems and healthcare settings. Without consistency in those acronyms and terms, medical records would be cumbersome to understand, and patient care would suffer. According to HIMSS (Healthcare and Information Management Systems Society), if we consider the numerous healthcare professionals that are involved in a single patient's care--physicians, nurses, pharmacists, medical assistants, physical therapists, and so on--the need for standardization is clear (Why do we need interoperability standards?).

Laurin, I think you bring up a good point here. Personally, I am glad there are words we click on to describe our assessment in the EMR. We don't have to interpret what the person who charted before us meant. Crackles mean crackles. We don't have to interpret something like, "Chest sounded like rubbing two candy wrappers together." That is a silly and probably far-fetched example, but it does make my point. We have standard words in out EMR charting at Methodist that can only be interpreted one way. It is to the point, and I think it aids in patient care.

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I tried to quote Laurin above and it didn't work. The first paragraph a quote from one of her posts. UTGE2-CW

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In order for a patient to receive the highest level of care, different healthcare providers must be able to access the patient's electronic health record (EHR). Furthermore, as a patient ages, their possible co-morbidities allow them the be treated by many different healthcare providers (Le, 2013). In this scenario, it is extremely important for standards to be set and followed so that this data can be interpreted by all of the healthcare providers that are caring for that patient. Through existing standard that regulate how to document within a patient's EMR, all of the healthcare providers can be assured that they are receiving the most accurate, up-to-date information concerning that patient's progress and plan of care. The concept of accuracy is becoming extremely important when considering the rate of patient readmission, and the impending penalty that will accompany patient readmission (Le, 2013).

Overall, interoperability and standards allows for the deliverance of better healthcare to patients. Since the patient's EMR contains so much information relating to allergies, previous diagnoses, medications, existing diagnoses, lab values, and other pertinent medical information, it proves to be a extremely valuable resource when providing healthcare. This system allows for multiple providers to access and document within a patient's EHR with consistency. Through creating a standardized environment that allows healthcare providers to communicate effectively, healthcare can be provided to right patients at the right time.

References:

Le, P. (2013, October 01). Strategic interoperability: Unleashing the full potential of ehrs . Retrieved from Strategic interoperability.: EBSCOhost

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UTGE2-KM

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I think Kyle makes a great point in bringing up accuracy. We need the standards to prevent the chaos and facilitate communication among caregivers, but we need accuracy to ensure quality patient care as well. We need to make sure that we document thoroughly. If all caregivers are looking at the EMR, we as nurses better make sure we are giving everyone the information needed to take the best care of the patient. Hopefully, other caregivers will do the same for us. The EMR is what we are all relying on to paint the picture of the patient. We need the standards to make the interoperability easier to communicate, but we have to make sure what we are communicating helps everyone take the best possible care of the patient. UTGE2-CW

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In order for a patient to receive the highest level of care, different healthcare providers must be able to access the patient's electronic health record (EHR). Furthermore, as a patient ages, their possible co-morbidities allow them the be treated by many different healthcare providers (Le, 2013). In this scenario, it is extremely important for standards to be set and followed so that this data can be interpreted by all of the healthcare providers that are caring for that patient. Through existing standard that regulate how to document within a patient's EMR, all of the healthcare providers can be assured that they are receiving the most accurate, up-to-date information concerning that patient's progress and plan of care. The concept of accuracy is becoming extremely important when considering the rate of patient readmission, and the impending penalty that will accompany patient readmission (Le, 2013).

Overall, interoperability and standards allows for the deliverance of better healthcare to patients. Since the patient's EMR contains so much information relating to allergies, previous diagnoses, medications, existing diagnoses, lab values, and other pertinent medical information, it proves to be a extremely valuable resource when providing healthcare. This system allows for multiple providers to access and document within a patient's EHR with consistency. Through creating a standardized environment that allows healthcare providers to communicate effectively, healthcare can be provided to right patients at the right time.

References:

Le, P. (2013, October 01). Strategic interoperability: Unleashing the full potential of ehrs . Retrieved from Strategic interoperability.: EBSCOhost

Kyle makes a great point! In order for there to be effective interoperability, following the standards of care is vital. The standards of care allow effective communication between health care providers, as well as accurate interpretation of the data entered into the EHR. The Hospital Readmissions Reduction Program is so important. Hospitals will receive a 2% revenue penalty from Medicare this year, and increases to a 3% revenue penalty in 2015 if a patient is readmitted to a hospital for the same diagnoses (Le, 2013). This, in addition to patient safety, is crucial for health care providers to understand when entering patient information. Accurate documentation is extremely important, and is quickly becoming one of the most critical components of the EHR.

Le, P. (2013, October 01). Strategic interoperability: Unleashing the full potential of ehrs. Retrieved from Strategic interoperability.: EBSCOhost

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UTGE1-LR

According to Sewell and Thede, “interoperability is not possible without standards” (p. 266). First, “interoperability” is defined as “the ability of one or more systems to pass information and to use the exchanged information” (Sewell and Thede, 2013, p. 266). Furthermore, a “standard” is “an agreement to use a given protocol, term, or other criterion that has been formally approved by a nationally or internationally recognized professional trade association or governmental body,” (Sewell & Thede, 2013, p. 266).

Establishing set standards is germane to creating a system that is interoperable. For example, a set medical terminology and medical acronyms are used in the electronic healthcare records to facilitate understanding of a patient's health across multiple systems and healthcare settings. Without consistency in those acronyms and terms, medical records would be cumbersome to understand, and patient care would suffer. According to HIMSS (Healthcare and Information Management Systems Society), if we consider the numerous healthcare professionals that are involved in a single patient's care--physicians, nurses, pharmacists, medical assistants, physical therapists, and so on--the need for standardization is clear (Why do we need interoperability standards?). It is difficult to imagine a time when diseases were not even classified in a standardized way, but it was 1900 before there was any agreement in medicine on standardizing the causes of death. Currently, the ICD (International Statistical Classification of Diseases and Related Health Problems) maintains a list of known diseases and injuries that is “described, classified, and assigned a unique code” (Sewell & Thede, 2013, p. 270). In the United States, the use of these codes is required by the Health Insurance Portability and Accountability Act (Sewell & Thede, 2013, p. 270).

As globalization continues, standardization of medical language and protocol will become increasingly important. As Sewell and Thede point out, quick access to health data concerning disease outbreaks has become increasingly important as individuals are traveling between states and nations more than ever before .

Healthcare and Information Management Systems Society. 2014. What is interoperability? Retrieved April 18, 2014 from https://www.himss.org/library/interoperability-standards/what-is

Sewell, J., & Thede, L.Q. (2013) Informatics and nursing: Opportunities and challenges.(4th ed.). Philadelphia: Lippincott.

Laurin, you make a great point! It is becoming so much more important to have a standardization of terminology and language used in entering patient information. There is so much room for error when there is not a nationwide understanding of the expectations regarding documentation in the EHR. This is a huge patient safety issue. If the proper terminology is not used, it will lead to misinterpretation of patient information which is vital to provide quality care and ensure a quality outcome. This is so important for health care providers to understand when using EHR. The EHR is such a benefit to patient care in so many ways, but if used incorrectly it will have a huge negative impact on the outcome.

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In response to cpayne28:

Interoperability and standards run hand in hand. One can not be achieved without the other. Healthcare agencies need to adopt standards pertaining to documentation to ensure accuracy throughout the patient's EMR. Once these standards are in place, then every healthcare provider for that patient can retrieve accurate, up-to-date information concerning that patient's care. Tori dives further into this concept by using practical application within the healthcare setting. The use of universal terms and abbreviations prevent misinterpretation among healthcare providers. Whereas the EMR has become a cornerstone within the healthcare setting, its full potential can only be reached through the use of standards that allow interoperability.

UTGE2-KM

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In response to cwoodru5: I really like how Candice can relate the use of standards and today's practice. She is absolutely correct about the headache it would cause if standards were not implemented in todays healthcare setting. Forget interoperability, there would be none. Standards are essential to ensure that congruence is established within a patient's EMR. Candice goes on to explain the benefits of standards, which there are many. Altogether, standards are essential and allow intraoperability to work. Healthcare professionals are able to access, intrepret, and make healthcare decisions that better the patient.

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The ability of different systems and devices to exchange and interpret data is known as interoperability (HIMSS, 2014). In the healthcare setting the ultimate goal of interoperability is for clinicians, labs, hospitals, pharmacies, and patients to share data related to the patient regardless of application or application vendor (HIMSS, 2014). There are several different types of healthcare information technology interoperability, but the focus of this discussion will be on structural interoperability.

Structural interoperability pertains to how the data is formatted. In order for data to be shared among all the different healthcare providers, it must be able to move from one system to another so that its purpose and meaning is preserved and unaltered (HIMSS, 2014). In simple terms the concept of standards driving interoperability is exemplified by what took place when videotape technology first got its start.

There were two different types of recording formats (standards). Some video recorder manufacturers used the Beta Max format, and some used the VHS format. The VHS format eventually became the most popular, and movie distributors knew it was in their best interest to use the VHS format when recording their movies. Even though there were numerous manufacturers, as long as the machine played the VHS format, the VHS tape would work in it.

In much this same way, structural interoperability of healthcare information can be accomplished once a standard (format) is agreed upon. If a hospital is running one kind of system, and the pharmacy is running another kind of system, and a physician is running yet another kind of system, the exchange of data won't take place unless the data is formatted using the same standard.

References

Healthcare and Information Managements Systems Society. 2014. What is

interoperability?Retrieved April 17, 2014 from

https://www.himss.org/library/interoperability-standards/what-is

Posted by UTGE1-SW

UTGE1-MH

SW,

I really liked how you used the example of the VHS!! That is a great way to think of "standards". You're right. If the manufacturers did not use the popular VHS format, their movies would not play, thus be useless. That is exactly how I picture patient data/information. If a healthcare team member cannot access the needed patient information, the information is useless, which affects patient care. I also liked how you pointed out how important it is for different members of the healthcare team to be able to access the same patient information. I know I often forget that I am not the only one using the patient's EMR. There are multiple doctors, nurses, physical therapists, pharmacists, social workers, speech therapists, etc. that all use the patient's EMR to plan their particular area of care. If all of the members of the healthcare team were not on the same page in knowing what is going on with the patient and looking at the same documented data, the patient's care would be affected.

Your post reminds me of the example that Sewell and Thede use in the book. Sewell and Thede (2013) point out that when a patient is seen for a follow-up appointment in an outpatient clinic, it is not uncommon for the outpatient clinic not to be able to access the patient's inpatient data. This is why it is essential for standards with interoperability to exist. In order for the patient to receive the best of care, his/her EMR needs to be able to accessed by all healthcare providers.

Sewell, J., & Thede, L.Q. (2013). Informatics and nursing: Opportunities and challenges.(4th ed.). Philadelphia: Lippincott.

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UTGE1-MH

LR,

Great post! I couldn't agree more about using standards with medical terminology and acronyms. In my opinion, if there were not a set protocol on accepted medical acronyms, no patient EMR would be interoperable. Medical terminology and acronyms is healthcare's own special language (Sewell & Thede, 2013). People would interpret things differently if there was not a set standard. I know in my clinical experience I have come across abbreviations that did not make sense in the context they were being used. This could cause great harm to a patients care, especially in medication administration. For example, in a patient's EMR, I saw the abbreviation "hs". I automatically assumed that this meant "at bedtime"; however, the provider meant for it to be interpreted as "half strength". One could see how misinterpretation such as this could have a great impact on the patient.

I also like how you take into account globalization. People travel all over the world nowadays. This makes the need for medical terminology and acronym standards even greater. Patient information must not be interoperable just within their hometown, but really worldwide. You never know when appendicitis might hit you while in the midst of China!

Sewell, J., & Thede, L.Q. (2013). Informatics and nursing: Opportunities and challenges.(4th ed.). Philadelphia: Lippincott.

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