As you start to conduct research on the implementation of a new electronic health record (EHR) in your organization, you know that you have to consider the importance of controlled medical vocabulary (CMV). You know that without a CMV in place, the EHR may be impossible to establish. Discuss the following:
- Explain how CMVs are key to effective information operability and achieving modern health care goals.
- Discuss some of the complexities that may be involved to create and maintain a CMV.
Use at least two references and cite them according to APA format guidelines.
Deliverable Length: 300-500 words
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Introduction:
The implementation of electronic health records (EHRs) is becoming increasingly important in modern healthcare. However, without a controlled medical vocabulary (CMV) in place, the EHR may not be effective. This paper will discuss the importance of CMVs in achieving health care goals and the complexities involved in their creation and maintenance.
Explain how CMVs are key to effective information operability and achieving modern healthcare goals.
Controlled medical vocabularies (CMVs) are standardized terminologies used to describe medical concepts and are key to effective information operability and achieving modern healthcare goals. They help ensure accurate and consistent documentation, which can improve the quality of patient care, reduce errors, and increase efficiency. For example, using a standard vocabulary, such as SNOMED CT, allows clinicians to communicate and share health information across different systems and organizations, facilitating interoperability. This is particularly important in the era of big data, where large datasets need to be mined for insights, and machine learning is increasingly used to improve healthcare outcomes.
Discuss some of the complexities that may be involved in creating and maintaining a CMV.
Creating and maintaining a CMV can be complex, and several challenges must be overcome. One challenge is ensuring that the vocabulary is comprehensive, covering all medical concepts and unique to each discipline. This requires input from subject matter experts and extensive testing to ensure that the terminology is accurate and relevant. Another challenge is keeping the vocabulary up-to-date and ensuring that it remains relevant as new medical concepts and practices emerge. This requires ongoing revision and monitoring to ensure that the vocabulary remains current and accurate. Additionally, training staff to use the vocabulary can also be challenging, as it requires a significant time commitment and resources to ensure that staff are proficient in its use.
References:
1. Nadkarni PM. Controlled medical vocabularies: how they are constructed, and how to use them for information-retrieval purposes. Medinfo. 1995;8(Pt 2):1140-1144.
2. Alotaibi YK, Federico F. Using electronic health records for clinical research: Benefits and challenges. Journal of Medical Systems. 2014;38(9):1-9.