Nursing Terminology Comparison - Essay Sample

Introduction

GIGO is a term used in a computer that refers to garbage in garbage out. This can be used to define that when good data is inputted, good information will come out. Data is essential for better health. It should have qualities such as accessible, timely, accurate, comprehensible and efficiently gathered. Data is clear if its definition is consistent across all avenues. The use of a common terminology ensures that interested parties get to communicate efficiently and hence improve the delivery of quality care (Monsen, Honey & Wilson, 2010).

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Coded data helps in the standardization of data. So as to enhance standardization, healthcare systems have embraced the use of codes instead of text in database fields. Text data refers to data made up of paragraphs, sentences, and words. These uncodified data limits or hinders optimal data sharing as well as data interpretation. Standard codes are used for the accurate interpretation of data by other users. Additionally, it allows seamless sharing of data to other users across many fields.

SNOMED-CT

SNOMED-CT stands for Systemized Nomenclature of Medicine. CT refers to clinical terms. It is a standard clinical terminology that is not only safe but also an effective communication tool in healthcare. It has specific support for multilingual translation and is used across many countries hence eliminating language barrier. SNOMED-CT equally provides support to other search and management functions within this terminology. It creates a platform that allows combining of terms according to rules. Varied interpretations of the data records are reduced significantly. The advances in healthcare terminologies are incorporated on the latest information since it is updated at least twice a year (ONC, 2017).

The use of electronic health records has been hailed as the best strategy for optimizing health care, It entails meaningful use of health data which integrates complex processes, interoperability, and workflow. In order to achieve this, there is a need to make use of interface standards for point of care documentation. Interface terminologies and new clinical datasets are being embraced across and being implemented in electronic health records globally. Codes provide a mechanism that makes it possible for terminology to be plugged at a particular place while providing relationships between other concepts. Some of the meaningful objectives supported by SNOMED CT include:

• Provide a detailed summary of each care transition.
• Record the smoking status of patients
• Record and also track changes of vital signs in a patient
• Identify and report cancer case to state cancer registries
• Record the family health history of patients as structured data
• Maintain an up-to0date list of active and current diagnoses.

SNOMED CT was first developed in 1965 as SNOP Systematized Nomenclature of Pathology. It was used to describe anatomy and morphology. In 1975, it was expanded to SNOP so as to meet the expansive needs of medicine. The term CT was incorporated in 2002. In 2013, the federal government made it a mandatory for all EHR systems to include SNOMED CT (Lundberg et al., 2009). SNOMED CT is made up of three critical components namely:

1. Relationships- forms a link between concepts. It is crucial in defining each concept
2. Descriptions- These are terms that can be understood by humans. They are referred as concepts.
3. Concepts- these are clinical meanings

Besides the mentioned components, SNOMED CT also supports

References sets- it is a mechanism used to present references to SNOMED CT. It includes language preferences, aggregation hierarchies, maps and subsets

Expressions- This is a structured combination of either one or more concept identifiers. Expressions are pegged to give a clinical meaning.

ICD 10

The International Classifications of Diseases (ICD) helps in monitoring prevalence and incidence of diseases among other health-related problems. The ICD 10 has been used globally since 1994. ICD-10 CM refers to clinical modification while ICD-10 PCS refers to procedure classification n system. ICD 10 focuses on reporting procedures, research, quality management, and disease categorization.

ICD 10 allows better documentation of patient's information which is crucial when providing care. It is closer to a rational clinical representation as compared to other terminologies and provides a link between the clinical aspect of care and the financial basis. ICD 10 provides a clear reflection on the severity of a patient's condition. Additionally, it also provides information on how these conditions can be improved (Henderson, Shepheard, & Sundararajan, 2006).

ICD 10 provides a consistent representation of procedures and conditions that might not be reflected by other terminologies. This ensures better patient safety and avoids unintended adverse consequences of care delivery. Patients also have better insights since conditions and services represent the reality of care accurately. Moreover, it fosters the effective coordination of communication by providing an additional layer of data accuracy (Henderson, Shepheard, & Sundararajan, 2006).

Another advantage of using ICD 10 is it has boosted health surveillance. Epidemic trends are tracked hence the safety of the citizens is assured from diseases crossing borders. This has also streamlined identification of opportunities according to populations hence help in reduction of the burden of illness.

Differences

SNOMED CT is input systems while ICD 10 are output systems.

SNOMED CT supports clinical care process while ICD does not have a clinical content coverage since classifications are not intended to represent the complete clinical content of a health record.

SNOMED CT codifies primary documentation of clinical care that is captured in an Electronic patient record while ICD 10 is incapable of handling primary documentation of clinical care. This s because it fails to define individual clinical concepts as well as lacks granularity. It is intended for secondary data usage.

SNOMED CT is inadequate for serving secondary purposes for classification systems. O the other hand, ICD 10 is a common source of clinical data and readily available as a product of the healthcare reimbursement process (Steindel, 2012).

Similarities

ICD 10 and SNOMED CT work together via mapping. This allows clinical information captured at a very granular level to be aggregated for reporting, reimbursement and statistical analysis purposes. As compared to other standardized terminologies, ICD 10 permits robust mapping with SNOMED CT since it uses a combination of a reference terminology.

They both need to be used with an electronic patient record.

The need for an information model for optimal functioning. This represents the meaning of clinical information.

Case Examples

SNOMEDC-CT

Leeds Teaching Hospitals NHS Trust

Leeds Teaching Hospital is a leading frontier in the delivery of care services treating at least a million patients annually. It boasts of a workforce of 14, 000 staff who help in the delivery of quality care. However, Leeds was faced with a challenge, Electronic system diagnosis was selected from a list of approximately 40 high-level diagnoses. Introduction of SNOMED CT helped in the reduction of duplicated data entry and ensure a consistent recording of data, The SNOMED Ct was mapped t the CDS fields. The subsets were then loaded into the existing electronic system. This enabled the creation of CDS returns automatically and improvement of data quality. It also allowed data comparison across different organizations. The CDS return codes also had a human-readable view for each term (NHS Digital, 2019).

ICD 10

A patient reported to the hospital with complaints on decreased flexibility in her legs. She is 67 years of age and had a history of multiple sclerosis for the last 25 years. She also had comorbidity of severe osteoporosis without a history of fracture. She used a power chair at home. An examination indicated that she had problems with muscle and joint functions and multiple sclerosis impact scale was 39% physiological and 82.5% physical.

Outlined below is clinical documentation with the use of ICD-10

• G35 Multiple Sclerosis
• R29.6 Repeated falls
• R27.8 Lack of coordination
• M81.0 Age-related osteoporosis without current pathological fracture

Conclusion

Standardized terminologies such as SNOMED CT and ICD are equally important in healthcare systems. Since each terminology offers something unique, health practitioners should hence strike a balance between SNOMED CT and ICD and can also be combined to achieve optimum benefits. According to WHO, ICD is a tool that dragonizes epidemiology, the clinical purposes and management in the health sector. This analyses the general situation of the population groups and monitors the prevalence and incidences of diseases. On the other hand, SNOMED CT allows the input of detailed notes thus the phyiscians can input data for each patient in electronic health record.

References

Monsen, K.A., Honey, M., & Wilson, S. (2010). Meaningful use of standardized terminology to support the electronic health record in New Zealand. Applied clinical informatics, 1 4, 368-76.

The Office of the National Coordinator for Health Information Technology. (2017). Standard Nursing Terminologies: A Landscape Analysis. https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf

Henderson, T., Shepheard, J., & Sundararajan, V. (2006). Quality of diagnosis and procedure coding in ICD-10 administrative data. Medical care, 1011-1019.

Lundberg, C.B., Warren, J.J., Butcher, H.K., & Johnson, M.R. (2009). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care.

Steindel, S.J. (2012). A comparison between a SNOMED CT problem list and the ICD-10-CM/PCS HIPAA code sets. Perspectives in health information management, 9, 1b.

NHS Digital. (2019). EXAMPLES OF SNOMED CT USE - Delen: Home - NHS Digital. Retrieved from https://hscic.kahootz.com/connect.ti/t_c_home/viewcontent?contentid=301171