LAS VEGAS—HHS' Office of the National Coordinator for Health Information Technology is pushing nurses across the nation to use common language in electronic health records.
The office's chief nursing officer, Rebecca Freeman, is promoting the use of the LOINC (Logical Observation Identifiers Names and Codes) and Snomed (Systematized Nomenclature of Medicine) codes for nursing documentation. The aim is to end a cacophony of more than a dozen different terminologies in use today, she said.
Freeman said it's critical to achieving the government's interoperability goals, and that goal will become increasingly important to providers as the nation moves toward value-based payments.
The reason is, even if every EHR system could send and receive data seamlessly to other systems, there would still be a communication problem with nursing data, Freeman said. Nurses use different terminology that would need to be normalized to be understood by the different systems and their users, an extremely labor-intensive process.
HHS Secretary Sylvia Mathews Burwell, in her keynote speech Monday at the Healthcare Information and Management Systems Society convention in Las Vegas, and ONC chief Dr. Karen DeSalvo, in her question and answer session at the nursing informatics symposium, both emphasized that promoting interoperability will be a No. 1 priority for the feds this year.
In December, the ONC released an update of its “advisory” on the best health IT interoperability standards and implementation specifications, and they included the recommendation that vendors and nurses use LOINC and Snomed for nursing documentation.
Freeman, who landed the HHS job in September after stints in nursing informatics at the Hospital Corporation of America and the Medical University of South Carolina, said she'll spend time this year working with nursing leaders. She'll reach them through their professional associations and nursing education programs and by meeting with boots-on-the-ground nursing informaticists to try and convince them to shift to the LOINC and Snomed codes.
Some nursing informatics leaders need no convincing.
“It's not an easy task, but it's necessary,” said Michelle Machon, director of clinical and nursing informatics at the Cleveland Clinic in Abu Dhabi who was attending the HIMSS nursing informatics symposium. In Abu Dhabi, clinicians and patients use multiple languages, but “the business language is English,” Machon said. “We standardize our order sets because we know it provides better care. We standardize prescriptions because we know it makes it safer.”
Standardizing terminology for nursing documentation is the same thing.
“We just have to if we're going to progress and produce standardized care,” Machon said.