Standardized EHR Language Needed

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Hospital Employee Health

June 17, 2014

Standardized language in healthcare is not yet universal, which can cause problems when implementing electronic health records (EHR) in an employee health setting.

There are a dozen different standards just for nursing, says Karen A. Monsen, PhD, RN, co-director of the Center for Nursing Informatics at the University of Minnesota in Minneapolis, MN.

One of the key benefits of an EHR is how easily it can be used to analyze data and trends. From an occupational health perspective, this could inform decisions about vaccinations and wellness campaigns. But to pull out the best data one needs standardized terms. For example, it's not as useful if information about tuberculosis vaccinations is labeled three or four different ways.

"How can we optimize our best practices?" Monsen asks. "How can we use standards for documentation and how can we get data to show us if we've made a difference?"

The answer is to use standardized language in all electronic documentation, she says.

"That in turn generates good structured data you can use for program evaluation," Monsen adds.

If all hospitals were to agree to standardized language there could be many more benchmarking possibilities.

One area of study might be hearing loss prevention in the workplace, says Madeleine Kerr, PhD, RN, an associate professor at the University of Minnesota. Even with electronic health records for collecting hearing loss data, it's difficult to understand on a national level whether prevention programs are working because the databases are not using standardized metrics, Kerr explains. Agreeing on standards is the challenge.

"Every discipline has its own idea of what standards are important and what needs to be used," Monsen says.

"Using standards forces us to give up our fondness for the English language and how we can capture all nuances of diagnosis or patient concern," she explains. "For instance, using the patient's own words—we have to give up some of this when we use standards."

Standardized language for EHRs requires classifications into small buckets. It also requires training, teaching staff how to use the standardized terms, Monsen adds.

"That is challenging; people don't really like it, and we have to show them why it's important to go to the trouble to learn the standard," she says.

When occupational health departments switch to electronic health records staff will have to learn to document with checkboxes instead of descriptive words.

"It's about healthcare quality, but sometimes it's hard for people to see that because the health records have become such a big part of our healthcare day," Monsen notes.

Another barrier that arises when implementing EHRs and standardizing language is making sure information is easily accessible.

"It's a workflow issue," Monsen says. "We have the technology and want to manage it, so the next generation of this is to make it much more accessible and usable."

A responsive implementation stage is crucial to the EHR success, Kerr notes.

"I think the key is to have this standardized, common language embedded in these electronic systems in a way that health providers can use it," she says. "Early in the process, work with your information technology department to design it, and have end users—not just at the executive level, but people on the ground—involved from the very beginning."

Monsen's experience implementing EHR was in the 1990s. She was a manager of nurses who had to begin using electronic health records. She saw initial resistance, but soon the EHR use changed how nurses communicated about patient care and it made staff meetings much more efficient and effective, she recalls.

"We standardized our care plans, personalizing them for each individual, and we used that as the basis of our care," Monsen says. "Soon we were able to demonstrate our outcomes and increase funding of our program."

While using EHR in a general healthcare setting is different from using it in a hospital employee health setting, similar benefits could occur, she notes.

"With this kind of health record we could show whether we have a hearing problem or diabetes, overweight issues, substance use," Monsen says. "We can incorporate all of this into a holistic assessment using a standard tool, and it supports employees in different ways than if we just made a checkmark on a form to show they had their hearing checked."

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