Meaningful Use of a Standardized Terminology to Support the Electronic Health Record in New Zealand

Abstract

SummaryMeaningful use is a multidimensional concept that incorporates complex processes; workflow; interoperability; decision support; performance evaluation; and quality improvement. Meaningful use is congruent with the overall vision for information management in New Zealand. Health practitioners interface with patient information at many levels, and are pivotal to meaningful use at the interface between service providers, patients, and the electronic health record. Advancing towards meaningful use depends on implementing a meaningful interface terminology within the electronic health record. The Omaha System is an interface terminology that is integrated within Systematized Nomenclature of Medicine -Clinical Terms (SNOMED CT ® ), and has the capacity to disseminate and capture information at the point of care because its codes are simple defined terms. Two community nursing and allied health providers who are considering using the Omaha System in clinical systems for gathering intervention and outcomes data within the personal EHR include Nurse Maude and the Royal New Zealand Plunket Society. Help4U is investigating using the Omaha System as a way to standardise health terminology for consumer use. The Omaha System is also a good fit with the Midwifery and Maternity Providers Organisation (MMPO) existing clinical information system to describe and capture data about interventions currently recorded as free text. As a country that promotes access to affordable primary care and free hospital care, within an environment constrained by resource limitations, maximizing the use of data is key to demonstrating health outcomes for the population.

Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences

“…Furthermore, the use of standardized terminologies could improve communication among nursing staff themselves and communication with other healthcare professionals, because recognizable words and distinguishable terms are used (Rutherford, 2008;Thede and Schwirian, 2011). Another benefit of standardized terminologies is that these terminologies provide a certain structure in electronic health records that could facilitate the reuse of documented data, for instance as information sources for scientific research or for quality assurance (Monsen et al, 2010). Besides, standardized terminologies could facilitate the comparison within and between care organizations of the effect of nursing interventions on patient outcomes (Rutherford, 2008; The Office of the National Coordinator for Health Information Technology, 2017).…”

Implementation of a nationwide electronic health record (EHR)

“…Furthermore, in September 2010, New Zealand launched the National Health IT Plan. The main challenge is the difficulty of the implementation of a national patient portal taking into account the current low level of interoperability among EHR systems and, also, considering that there are legacy systems which are still operable (Monsen et al, 2010).…”

Linking home care interventions and hospitalization outcomes for frail and non‐frail elderly patients

“…They have implemented a systematic, standardized assessment process and core care plans for typical family health patients, as well as procedures for implementing these standards (Martin, Monsen, & Bowles, 2011). Similar efforts are underway in home care agencies in the Netherlands and in New Zealand (Monsen, Honey, & Wilson, 2010). …”