Clinical terminology and the quest for the perfect patient record

When exchanging information about a patient – and piecing together a complete and accurate “digital twin”– sharing a common clinical terminology is key.
clinical terminology

Given the tremendous volume of data used to document patient care and conditions, painting a comprehensive picture of a patient’s health should be fairly easy. But accessing a true digital twin in the electronic health record (EHR) isn’t a simple task.  

Although clinical data is abundant, it is also complex, frequently unstructured, and riddled with gaps and inconsistencies. (As a result, analytics and insights grounded in this data are also inevitably flawed). 

Many factors contribute to the distortion of our digital reflection in the patient chart. Among them are the prevalence of data siloes, the inaccessibility of certain types of data, and variations in clinical terminology. The excerpt below, from the IMO Health insight brief, Bridging reality and medical records: Data quality and the elusive digital twin, explores some of the challenges that arise from inconsistent terminology use within the EHR.  

To read the excerpt, keep scrolling, or to download the full brief, click the button below. 

INSIGHT BRIEF

Bridging reality and medical records:
Data quality and the elusive digital twin

Variations in terminology

When documenting patient conditions in the electronic health record (EHR), clinicians use the words they’re most comfortable with, whether it’s short forms, acronyms, slang, or more formal phrases. For example, one physician may say essential hypertension, another primary hypertension, while yet another may write HTN. This practice introduces a great deal of variability into the patient record if these synonyms aren’t harmonized to a single, standard term – which is then precisely mapped to standard codes for billing and reporting activities. 

In the absence of a universal term, diagnosis data can be misinterpreted, omitted, or lost in translation as it moves from one provider to the next or through data lakes and health information exchanges (HIEs) . While this may

 result in lost reimbursement for a provider, the patient’s situation is more dire. An incomplete digital twin is a flawed representation of a patient’s health and using that data can contribute to sub-optimal care – or the absence of care altogether. 

 

    

For more on what stands in the way of creating a more complete patient record, download Bridging reality and medical records: Data quality and the elusive digital twin.

If an on-demand webinar is more your speed, check out Words matter: Is your structured terminology enough? Or, if you’re curious about the process of creating IMO Health terminology, click here.

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