The concept of a universally accepted standardized clinical language
is fundamental to solving the issues facing the health care community
worldwide. No reliable or meaningful analysis of health care outcomes
can be accomplished without widespread consistent collection of detailed
clinical data.
The use of a standardized vocabulary insures that the information collected
for analysis is accurate, specific, precise and comparable. Over thirty
researched standardized health care languages exist today, and it is
from this collection that a comprehensive set of component languages
was assembled for use in EMRitus.
The languages implemented and supported in EMRitus are:
- ICD-9-CM
- CPT
- NIC
- NOC
- NANDA
- Ergo's
Health Observation Language
We
are currently reviewing language from SNOMED and are evaluating inclusion
of language from LOINC, the Read Codes, DSM-IV and other UMLS component
languages.
Ergo's Health Observation Language
Throughout our extensive research into standardized language we identified
one crucial area that had not been satisfactorily addressed. We found
no single published or accepted language that comprehensively and logically
described the discrete facts about a patient’s health status that are
required for scientific analysis of clinical data and unambiguous analysis
of patient outcomes.
This language, which was absolutely crucial to our ability to be successful
in creating a clinical record that could support scientific outcome measurement,
did not exist. We invested years of clinical expertise to develop this
critical language, which we call the Health Observation Language. This
language incorporates a dictionary that currently contains approximately
20,000 discrete facts that describe precisely, in a form that can be analyzed,
the state of a patient’s health. It is the changes in these facts that
are the basis for accurate measurement of outcome progress, the cost of
care delivery and precise measurement of the relative efficacy of care
delivery protocols.
Ergo's Health Observation Language has been arranged into over 3,000 topic
oriented tabs which have been logically grouped onto approximately 600
subject specific dialogs. These dialogs can be arranged by clinical users
into any workflow arrangement or protocol they desire using the template
builder included in EMRitus.
A template can be built easily in a matter of minutes and is then available
for continuous re-use whenever required. Through the unique and intuitive
user interface in EMRitus all of these standardized languages are seamlessly
integrated to include over 100,000 terms and medical codes. The resultant
system is incredibly easy to learn and fast to use. In very little time
clinicians can document encounters quicker and more comprehensively than
they could hand write or dictate them and at a fraction of the cost.
The resultant Electronic Medical Records are immediately available to
all clinical users who have appropriate access.
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