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Running Head: CONTROLLED VOCABULARIES IN HEALTHCARE SERVICES 1

CONTROLLED VOCABULARIES IN HEALTHCARE SERVICES 2

Nicole

Many health care organizations have invested significant effort in the electronic health record (EHR), as they provide a multitude of administrative and clinical functions (Brown, Pasupathy, & Patrick, 2019). Unfortunately, the input data is often times not standardized, structured, or even coded, resulting in a lack of interoperability (Brown et al., 2019). Because of such, data standardization is the main informatics component necessary for the flow of information through the national health information infrastructure (Brown et al., 2019). Having common standards in place allow clinical and patient safety systems to share an integrated information framework whereby data are collected and reused for multiple purposes to efficiently meet the broad scope of data collection and reporting requirements (Brown et al., 2019). Common data standards also support the effective assimilation of new knowledge into decision support tools, such as alerts of new drug contraindications and/or refinements to the care process (Brown et al., 2019).

While providers much prefer to document healthcare findings, processes, and outcomes using free text, as it is very rich in details, it also has a tendency of being ambiguous, has a great dependence on context, uses jargon and acronyms, and lacks rigorous definitions – an obstacle to the effective use of EHRs (Brown et al., 2019). As a result, data fields within EHRs populate explicit controlled vocabulary to increase semantic interoperability within e-health and, in turn, improve population health overall (Brown et al., 2019). All things considered, having standardized terminologies in place facilitate electronic data collection at the point of care; retrieval of relevant data, information, and knowledge; and data reuse for multiple purposes, such as clinical decision support, and quality/cost monitoring (Brown et al., 2019).

Reference

Brown, G. D., Pasupathy, K. S., & Patrick, T. B. (2019). Health informatics: A systems perspective (2nd ed.). Chicago, IL: Health Administration Press.

LUIS

Controlled terminology can be defined as a "Set of domain-specific multiword terms selected from natural language and organized by hierarchical and associative relationships" (). When it comes to interoperability, controlled vocabulary helps express new information in a structured and controlled way. This vital because when it comes to interoperability, new data from IT systems and software applications are constantly communicated and exchanged. Controlled vocabulary also helps in classifying that new data and information.

When it comes to population health, controlled vocabulary is very beneficial. When it comes to population health and public health issues, how the information and data is acquired is one factor that can help improve public health issues. Like stated before, this data and information needs to be expressed in a structured an controlled way. When it is expressed in such a manner it can then help promote better communication between individuals and organizations across different fields. Thus in turn controlled vocabulary can help promote better clinical care and decision making.

References

Brown, G. D., Pasupathy, K. S., & Patrick, T. B. (2019). Information Systems as Integrative Technology for Population Health. In Health Informatics: A Systems Perspective (2nd ed., p. 215). Chicago, IL: Health Administration Press.