For a patient’s clinical support system to function effectively, excellent communication is essential. This means that clinical notes, test results, and other documentation must be easily understood by an entire care team; however, that’s often easier said than done.
But when we begin to view a patient’s electronic health record (EHR) as a communication system – one in which clinical terminology captures high-quality data – we enable a care team to understand a patient’s journey in the way that best suits them.
A different way to communicate
In the past, the EHR functioned more like a walkie-talkie chat between the primary physician and the billing department and less like a conversation among caregivers. Codes, not clinical language, ran the show. This model siloed important patient information, making it difficult for additional providers to access, share, or use. Ultimately, the data would be EHR-bound and plagued by duplications, inaccuracies, and obscure notes – if a clinician could even get to it.
But today, robust clinical terminology can manage the relationship between clinical language and codes, resulting in a more collaborative way to communicate within the EHR. Rather than siloing information for use by the few, the EHR can now act as a communication system for the many – providing a detailed, ongoing conference call of all things patient data related.
So, who would be on this conference call?
- The patient and any family supporting their health needs
- All clinicians on an individual’s care team
- Long-term providers who need to do some digital time traveling to understand past patient problems
Yes, that means that with the right clinical terminology, today’s EHR can enable digital time travel. Sort of.
Less fantastically described, EHRs with a foundation of intuitive clinical terminology make it easier for providers to document with the specificity needed during future appointments with that patient. They can quickly understand what happened during past visits, their diagnosis, and how that may impact the reason for the current appointment – among many additional uses.
