Review of healthcare terminologies
Healthcare terminologies play crucial roles in healthcare institutions in enhancing the interoperability of data across systems.
Healthcare institutions could realize the benefits of electronic health records by adopting standard terminologies that are used by personnel across systems. Different healthcare terminologies are developed to fulfill specific purposes across departments in a hospital (Grain, 2010; Halley, Sensmeier & Brokel, 2009; Kuperman et al., 2010).
The initial step in using healthcare terminologies is identifying the purpose of a terminology. Terminologies in healthcare settings are either the billing or clinical (interoperability) standards. This essay describes the four healthcare terminologies of interest in surgical advanced nursing practice.
Logical Observation Identifiers Names and Codes (LOINC)
This database is available for free to all users, and it helps to identify names and codes associated with medical laboratory observations. Therefore, the terminology is used in many departments in a hospital like a laboratory and surgical procedures. Nurses, physicians, specialists, and laboratory technologists often utilize the terminology to record and interpret clinical observations (Kuperman et al., 2010).
The terminology is of interest in surgical advanced nursing practice because nurses can interpret laboratory results based on the components of the LOINC terminologies. A code (format: nnnnn n) in LOINC terminology describes the following:
- Component (parameter measured)
- Property (e.g., Volume and length)
- Time used to conduct the measurement
- Type of specimen measured
- Measurement scale used
- Procedures used
Based on the above components of the LOINC code, an example would be as follows: urea-volume-2 hours-urine-nominal-Urea Assay Kit. LIONS terminology is used by healthcare institutions across the world because it is translated into many languages.
Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT)
This terminology is used across systems in a hospital to interpret encoded data in healthcare records. It eliminates the confusion that would be encountered when using different terms to refer to medical conditions and symptoms (Grain, 2010). It enhances the exchange of clinical data across healthcare information systems and providers. It has the following four components: concept codes, relationships, reference sets, and descriptions.
A concept identifier is a unique number that is used to identify clinical data entries. ICD-10 code number 131.1- Diabetes Mellitus unspecified is a code which indicates that the entry is diabetes mellitus, but the type is unspecified. SNOMED-CT is used by healthcare organizations across the world.
Health Level 7 (HL7)
HL7 terminology is used by personnel across systems in a hospital to exchange, share, and retrieve information in electronic health records (Kuperman et al., 2010). The terminology is used by many healthcare organizations across the world because the programming language used is translated into many languages. A unique number is used to identify entries in electronic health records. HL7-3000098 is a code used to identify myocardial infarction.
RxNorm
RxNorm terminology is used to give unique names to drugs and drug channeling devices. It enhances interoperability and flow of clinical information across healthcare information systems. Its application is not limited by hardware and software compatibilities (Grain, 2010). It uses the following three parameters to describe drugs: ingredients, strength, and form of a drug.
For example, paracetamol 100mg tablet indicates that the drug described has paracetamol as the active ingredient, has the strength of 100mg and is in the form of a tablet. The terminology is applied in advanced surgical nursing practice because nurses interpret the drug information prescribed by physicians and specialists. The terminology is only used in the United States.
A description table
References
Grain, H. (2010). Clinical terminology. Studies in health technology and informatics, 151(1), 70.
Halley, E. C., Sensmeier, J., & Brokel, J. M. (2009). Nurses exchanging information: understanding electronic health record standards and interoperability. Urologic nursing, 29(5), 305.
Kuperman, G. J., Blair, J. S., Franck, R. A., Devaraj, S., & Low, A. F. (2010). Developing data content specifications for the nationwide health information network trial implementations. Journal of the American Medical Informatics Association, 17(1), 6-12.