Cmp105 Week 10 Assignment Page 2 Case Study Healthcare Data

Cmp105 Week 10 Assignment Page 2case Study Healthcare Data Standar

Perform the following tasks:

  • Review the case study documenting issues with a hospital's legacy data system and the transition to a new commercial system.
  • Create a PowerPoint presentation that includes:
    • Your name on the title slide.
    • Identification of two or more issues with the existing system.
    • Appropriate “work-around” solutions for using the existing system.
    • Overview of standard language used only in nursing.
    • Overview of a multidisciplinary standard language.
    • A set of five (5) open-ended survey questions for staff input on transitioning to the new system.
  • The presentation must be free of spelling and grammar errors.
  • Submit the assignment via Blackboard using the filename format: CMP105_wk10_assn_jsmith_mmddyyyy.

Paper For Above instruction

The transition of healthcare organizations from legacy information systems to modern, standardized systems is an ongoing challenge that requires careful analysis, planning, and stakeholder engagement. In this context, the case of a small community hospital illustrates critical issues associated with data standardization, system interoperability, and staff adaptation. This paper will explore two primary issues with the hospital’s existing system, propose practical “work-around” solutions, provide an overview of both a nursing-specific and a multidisciplinary standard language, and formulate staff survey questions to support a successful system transition.

Introduction

The healthcare sector continually evolves to improve quality, safety, and efficiency. A key component of this evolution involves adopting standardized health data and interoperable systems. The case of the community hospital, which relies on a decades-old homegrown system, exemplifies some of the inherent challenges in modernization efforts. These challenges include data inconsistency, limited searchability, and the absence of standardized terminology. Addressing these issues effectively ensures a smoother transition and sustained healthcare delivery improvements.

Identified Issues with the Existing System

Firstly, one significant issue with the hospital’s outdated system relates to the inconsistency and lack of standardization in clinical documentation. Since the system was developed in-house and involved custom templates and dropdown options, there is no comprehensive data dictionary or standard language to ensure uniformity across departments. Consequently, clinical data entered as free text or using non-standard terminologies hampers effective searchability and data retrieval, affecting clinical decision-making and research capabilities.

Another problem pertains to limited interoperability owing to disparate modules and interfaces, compounded by incomplete integration of outpatient clinics and doctor practice systems. The result is fragmented data that hinders seamless information flow within the hospital and across external entities, impacting patient safety and operational efficiency.

Work-Around Solutions

To address the first issue, staff can implement standardized templates and controlled vocabularies within their documentation practices temporarily. For example, clinical staff might establish consistent abbreviations and terminology within free-text notes, coupled with manual indexing when searching records, until the new system is implemented. Training sessions can reinforce the importance of using agreed-upon terms, even within the free-text environment.

For the interoperability issue, creating manual data reconciliation protocols can help. Staff could develop crosswalk tables mapping local codes to standardized codes used in the new commercial system, ensuring continuity of data during the transition period. Additionally, utilizing middleware tools or temporary interface software can facilitate partial data exchange until full integration is achieved.

Overview of Standard Language Used Only in Nursing

The Nursing Interventions Classification (NIC) is a standardized language specifically designed to describe nursing interventions. It provides consistent terminology used predominantly by nurses to document patient care activities. NIC is maintained by the American Nurses Association and keeps updating regularly, with cross-maps available to facilitate translation into other clinical terminologies. Its discipline-specific focus helps nurses communicate more effectively and align documentation with best practices in patient care.

Overview of Multidisciplinary Standard Language

SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a comprehensive, multidisciplinary clinical terminology system adopted globally. It covers a broad spectrum of healthcare concepts, including procedures, diagnoses, findings, and observable entities. SNOMED CT is designed for use across various clinical disciplines, facilitating interoperability and detailed clinical documentation. Its frequent updates and extensive cross-mapping with other terminologies make it a versatile tool for integrated patient data management.

Staff Input Survey Questions

  1. What challenges do you foresee in adapting your current documentation practices to the new standardized system?
  2. How can we support you in understanding and implementing the new standard terminologies?
  3. What suggestions do you have for training sessions to improve system transition effectiveness?
  4. In your opinion, which features of the new system would most benefit your workflow?
  5. What concerns do you have regarding data accuracy and searchability during the transition period?

Conclusion

Effective data standardization is crucial for improving healthcare quality and interoperability. Addressing the issues associated with the legacy system through practical work-around solutions paves the way for the successful implementation of the new commercial system. Moreover, understanding discipline-specific and multidisciplinary standard languages enhances documentation clarity and clinical decision-making. Engaging clinical staff through targeted surveys ensures their insights are incorporated, fostering a smoother transition and better patient outcomes.

References

  • American Nurses Association. (2020). Nursing Interventions Classification (NIC). ANA Publications.
  • Cimino, J. J. (1998). Desiderata for controlled medical terminologies in the twenty-first century. Methods of Information in Medicine, 37(4-5), 394-403.
  • Singh, H., et al. (2019). Interoperability of health information systems: Requirements, barriers, and solutions. Journal of Biomedical Informatics, 94, 103177.
  • Stearns, M. Q., et al. (2001). SNOMED clinical terms: Approaches and methodologies. Journal of AHIMA, 72(3), 38A–38D.
  • Hersh, W. R. (2002). Health information science and systems. Journal of the American Medical Informatics Association, 9(5), 471-472.
  • National Library of Medicine. (2019). SNOMED CT overview. Retrieved from https://www.nlm.nih.gov/healthit/snomedct/index.html
  • American Nurses Association. (2022). Standards of Practice for Nursing Documentation. ANA Publications.
  • Heritage, S. M., et al. (2000). The impact of standardized terminologies on clinical practice: A review. Journal of Nursing Administration, 30(8), 346-352.
  • Randell, R., et al. (2014). Enhancing healthcare interoperability through standardized terminologies. Journal of Medical Systems, 38(10), 113.
  • Australian Digital Health Agency. (2021). Health Terminology Services: SNOMED CT. Retrieved from https://www.digitalhealth.gov.au/your-health-it/clinical-terminologies/snomed-ct

Related Assignments