Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. D. Implications for the MDS


A reference terminology such as SNOMED CT is an essential underpinning of the NHII. An evolution from stand-alone reports such as the MDS to reports that are derived from clinical documentation systems requires close attention to terminology and other NHII related standards that will enable the re-use of clinical data across multiple applications (e.g., clinical decision support, alerts, quality monitoring, and reimbursement). The development and implementation of electronic patient medical record information systems that adhere to data standards required to achieve the NHII vision is a critical strategy for improving the quality of care in nursing homes.

This means that the development of an electronic clinical record for nursing homes and the derivation of quality monitoring and reporting from those clinical records must evolve in a fashion that is highly coordinated with the standards that will enable the NHII vision. The standards around clinical terminology systems that will allow the NHII vision to become a reality are particularly important to embrace. Failure to do so will only continue and exacerbate provider data collection burden and limit the scope, and, therefore, utility of the NHII for improving the quality of care in nursing homes.

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