The Notion of “Provider Friendly” in Healthcare IT

By: Charlie Harp

Introduction: The Goals of Healthcare Software

The point of a software application in a healthcare setting is essentially to (1) improve patient care, (2) assist providers in providing care, (3) make the processes involved in patient care more efficient, (4) leverage all of this to help manage costs over time, and (5) make sure I am getting paid for the services I provide.

The Role of Clinical Decision Support (CDS)

One of the main drivers of better software solutions is the notion of Clinical Decision Support or CDS. This is the idea that a provider can’t keep everything in their head, so we should augment them with extended clinical knowledge and the logic to apply it appropriately to their patient.

Challenges in Clinical Decision Support

This is a good idea, and we are slowly evolving in this direction. However, we are still struggling today, primarily because the knowledge is too blunt, and what the application knows about the patient is sketchy. This is due to a number of issues, two of which are the lack of structured/coded information and also the absence of information from other care venues.

The Role of “Meaningful Use”

To address this, we have “meaningful use,” which promotes structured data and sharing across traditional information silos. So to summarize, our goal is to capture and store clinically accurate structured terms so that our applications can leverage them for Clinical Decision Support.

Are We Strategically Positioned?

If you are with me so far, then we need to ask a question. Do the terminologies we are searching for, storing, and exchanging provide a foundation for what logically comes next? Are we strategically positioning ourselves for what is considered by many to be “the whole point” of an electronic medical record?

The Importance of Terminology

In order to provide good information in our patient records, we first have to find the term that most accurately describes our observations, diagnoses, treatments, and procedures. Finding the right term can be difficult because we humans are capricious.

Interface Terminologies vs. Reference Terminologies

Most people prefer an interface terminology because they are, by their very nature, more familiar. The problem with interface terminologies is that they can also serve to hide the actual reference terminologies that are, due to their conceptual nature, designed to drive what happens behind the scenes.

Guidelines for Good Interface Terminologies

When you are working with an interface terminology, you have to remember a few rules of thumb:

• Good interface terms are in conceptual alignment with the concepts they relate to.
• An interface term should not represent more or less information than their concept does.
• Good interface terms are complete.
• Good interface terms indicate both language and purpose.
• Good interface terms are stable.

The Role of Symedical Server

Clinical Architecture’s Symedical® Server provides comprehensive support for interface terminologies and reference terminologies alike.  The search engine handles common mnemonics, partial words, acronyms and abbreviations for any terminology.  It also supports the creation of local keywords, aliases and even local terms without compromising terminology updates from the source.  Our mission is to help you prepare for the next logical evolutionary step while meeting your tactical objectives today.  Give us a call and let us show you a better way forward.