Disciplines to Include in Research and Planning Sessions

• What disciplines should the nurse interview or include in their research and planning sessions and why?
• What terminologies should the nurse recommend and why?
• What are the benefits of using standardized terminologies within the electronic health record?
• What obstacles might the nurse informaticist encounter during the recommendation and/or implementation of these standardized terminologies?

Disciplines to Include in Research and Planning Sessions

1. Physicians: To provide insights into clinical workflows and patient care needs.
2. Pharmacists: To ensure medication management and reconciliation are accurately documented and communicated.
3. Nursing Staff: To understand the practicalities of bedside care and documentation.
4. IT Specialists: To address the technical feasibility and integration of terminologies into the EHR system.
5. Health Information Management (HIM) Professionals: To ensure compliance with health information standards and data quality.
6. Patient Representatives: To consider the patient’s perspective and ensure the system meets their needs.
7. Data Analysts: To understand the implications for data analytics, reporting, and quality improvement.

Recommended Terminologies and Their Importance

1. SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms): For comprehensive clinical terminology that supports the recording of clinical data across specialties and settings.
2. ICD-10 (International Classification of Diseases, 10th Revision): For standardized disease and condition coding, essential for billing and epidemiological research.
3. LOINC (Logical Observation Identifiers Names and Codes): For laboratory and clinical observations, ensuring consistent data exchange and interpretation.
4. CPT (Current Procedural Terminology): For coding medical procedures and services, crucial for billing and insurance purposes.
5. NANDA-I (North American Nursing Diagnosis Association International): For standardized nursing diagnoses, which support nursing practice and care plans.
6. RxNorm: For standardized naming of medications, supporting accurate prescribing and medication management.

Benefits of Using Standardized Terminologies Within the EHR

1. Improved Communication: Facilitates clear and precise communication among healthcare providers.
2. Data Consistency: Ensures uniformity in data entry, enhancing the reliability of patient records.
3. Enhanced Data Interoperability: Promotes seamless data exchange between different health information systems.
4. Better Patient Care: Supports evidence-based practice and comprehensive patient care by providing accurate and up-to-date information.
5. Efficient Billing and Reimbursement: Streamlines the billing process and improves the accuracy of reimbursement claims.
6. Enhanced Research and Analytics: Provides high-quality data for research, population health management, and clinical decision support.

Obstacles in Recommending and Implementing Standardized Terminologies

1. Resistance to Change: Clinicians and staff may be reluctant to adopt new systems and processes.
2. Training Requirements: Extensive training is needed to ensure all users are proficient with the new terminologies.
3. Integration Challenges: Technical difficulties in integrating standardized terminologies with existing EHR systems.
4. Cost: The financial investment required for purchasing, implementing, and maintaining standardized terminologies.
5. Data Migration Issues: Challenges associated with migrating existing data into a new standardized format.
6. Customization Needs: Standardized terminologies may need customization to fit specific organizational needs, adding complexity to the implementation process.

By involving a multidisciplinary team in the planning process, selecting appropriate terminologies, and anticipating potential obstacles, nurses can effectively contribute to the successful implementation of standardized terminologies within the EHR, ultimately enhancing the quality and efficiency of patient care.