As medical professionals increasingly adopt electronic health records, the need for capturing information in a way that can be easily and faithfully transferred to other providers will grow in importance. There is a lot of talk about interoperability, and organizations are working to make sure that everyone using the technology can speak the same language.
For example, the National Library of Medicine recently updated its RxNorm standard clinical vocabulary. The new standards are intended to be more accurate and precise in anticipation of the needs of providers who are using electronic health records.
Officials said that the update would make the system more useful to doctors because it normalizes the names of clinical drugs and then links these names to the nomenclature of many of the electronic systems currently used by pharmacies. It also has information about dosing, ingredient combinations and drug strength.
The intent is to guarantee that a doctor treating a patient for the first time in an emergency room can quickly and easily view that patient's entire prescription history, rather than relying on the individual to recount the information, which can often be unreliable, particularly in urgent situations.
"The RxNorm standard clinical drug vocabulary is the result of great collaboration between NLM, the FDA, the VA, and commercial drug information providers, as illustrated by this latest submission from First DataBank," said NLM Director Donald Lindberg.
Efforts like this complement wider projects that are currently underway to build systems that will allow providers to transfer information amongst one another quickly and securely. One example of this the HL7/HIE Health Story Implementation Guide Consolidation Project, which was recently launched by the Office of the National coordinator for Health IT.
On this project, the federal agency is collaborating with Health Level Seven International, a private authority that has worked to develop standards of interoperability, according to CMIO Magazine. The effort is working to bring together many different forms of information gathering with the result being a single standard.
"Frontline clinicians today need to have clinical documents; they need to have the rich narrative," HL7's Chair Bob Dolin told the news source. "The Health Story strategy says, how can we continue to support the frontline clinicians, how can we build upon this foundation that we need, but do it in a way that supports meaningful use?"
He added that setting standards that comply with the regulations of the government's electronic health records incentive program is a main goal of the project.