|
|
| |
| The Implementation of Standard Terminology in Electronic Health Record Systems and the Effect on Patient Outcomes: A Systematic Literature Review
Download PDF
|
Caitlyn Gildow, Dr. Bruce Lazar, MBA, DM
|
Abstract:
The implementation of uniform terminology and protocols to standardize healthcare procedures in healthcare organizations (HCOs) and data collection through electronic health records (EHRs) has rapidly increased in the United States since the implemented Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 (24). This standardization has shown to have significant impacts on healthcare (21), both reducing errors in healthcare delivery as well as creating new issues with interoperability (24). This study aimed to investigate whether the use of standard terminology compared to non-standard terminology improves clinical outcomes in HCOs that employ EHRs to manage patient health information (PHI). A search of MEDLINE and CINAHL Plus with Full Text was conducted. Four major themes emerged from analyzing 20 journal articles relevant to the research question. These include improving interdisciplinary communication, improving communication between providers and support staff, reducing patient injury, and standardized information dissemination. The results indicated that using standard terminology compared to non-standard terminology improves clinical outcomes in HCOs that employ EHRs to manage PHI. These results suggest that efforts to standardize terminology and processes within EHRs can ultimately continue to improve patient outcomes despite potential interoperability issues.
|
|
|
| | |