comp3 unit16 lecture slides

Terminology in Healthcare and Public Health Settings

Standards to Promote Health Information Exchange

This material Comp3_Unit 16 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number

1U24OC000023

Standards to Promote Health Information ExchangeLearning Objectives

• Define terms related to standardized terminologies

• Identify and define HIPAA standard code sets• Identify and define terminologies and

vocabularies that represent nursing care• Define and give examples of data interchange

standards

2Health IT Workforce Curriculum Version 3.0/Spring 2012

Terminology in Healthcare and Public Health Settings Standards to Promote Health Information

Exchange

Data Collection

Florence Nightingale

“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison… if wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present.”

Source: (Nightingale, 1863, p. 176)



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Health Information Standards

• Data set – List of the data elements with uniform definitions

• Standardized terminologies– Allow merging data for population health studies– Allow use of decision support– Allow mapping between terminologies for

patient-specific informationSource: (Giannangelo, 2010)



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Important Terms

• Data dictionary • Dictionary of the metadata for a particular data set• Definitions, principles and guidelines for each data

element• Specifies values for each element

• Metadata• Data about the data • Characteristics of each data element

Sources: (Giannangelo, 2010)(Amatayakul, 2009)



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Interoperability

• “the ability of different information technology systems to communicate, to exchange data accurately, effectively and consistently and to use the information that has been exchanged.”

• Date of birth formats– 3/22/56 – March 22, 1956– 22 March 1956

Source: (National Alliance for Health Information Technology, 2008)



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Interoperability

• Standardized terminologies/ ontologies– Patient diagnoses, interventions, outcomes

• Semantic Interoperability– Data means same thing to different users



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EHR Messaging Standards

• Also called• Data exchange standards• Interoperability standards

• Supports sharing of data• Safe• Accurate

• Protocols• Data definitions

Source: (Amatayakul, 2009)



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EHR Messaging Standards

• Numerous standards, including– American National Standards Institute,

Accredited Standards Committee X12-Insurance Subcommittee (ANSI-ASCX12N)

– Digital Imaging and Communications in Medicine (DICOM)




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Digital Imaging Communications in Medicine (DICOM)

– Facilitates the exchange of images and diagnostic information from manufacturers to vendors to providers

– Application is in any area using diagnostic images such as radiology, pathology, dentistry

– Standards address– Data structure– Data dictionary– Message exchange– Media storage– Mapping

Source: (Giannangelo, 2010)



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Health Level 7 (HL7)

• ANSI accredited SDO• Used for healthcare information exchange

around the world• Standards for

– Clinical data exchange– Vocabulary– Document architecture

Source: (Health Level Seven International)



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Classifications, Terminologiesand Vocabularies

• Classification systems– Group similar or related data

• Example: ICD-9-CM




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• Terminologies– Contain terms that represent a system of

concepts




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• Terminologies– Terms that represent a system of concepts

• Vocabularies– List or collection of words and their

meanings




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Clinical Terminologies

• Designed for the documentation by providers when delivering clinical care

• Allow for the information to be codified and used in EHRs



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Health Information Standards

• HIPAA national policy• NCVHS recommendations• National Library of Medicine

– Unified Medical Language System (UMLS)

Sources: (CMS)(Giannangelo, 2010)



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HIPAA Standard Code Sets

• HIPAA standard code sets– International Classification of Diseases, 9th Revision,

Clinical Modification (ICD-9-CM)– National Drug Codes (NDC)– The CMS Healthcare Common Procedure Coding

System (HCPCS)• Current Procedural Terminology, 4th edition (CPT)• Code on Dental Procedures and Nomenclature (CDT)



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International Classification of Diseases, 9th Revision, Clinical Modification

(ICD-9-CM)

• Modification of the World Health Organization’s ICD-9

• ICD-10-CM to be implemented in 2014• Numerous purposes

– Statistics and research– Reimbursement– Analyzing patterns of care– Strategic planning



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National Drug Codes (NDC)

• Used for reporting retail pharmacy transactions• Owned by the US FDA• Medications

• Prescription drugs• Over-the-counter (OTC) drugs• Drugs used by veterinarians

• Used for billing and reimbursement• Used for tracking drugs for many purposesSource: (US FDA, 2012)



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Healthcare Common Procedure Coding System (HCPCS)

• HIPAA standard code set– Level I

• Current Procedural Terminology (CPT) codes• Medical services and procedures performed by physicians

and other healthcare providers

Source: (American Medical Association, 2011)



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Healthcare Common Procedure Coding System (HCPCS)

• HIPAA standard code set– Level I

• Current Procedural Terminology (CPT) codes• Medical services and procedures performed by physicians

and other healthcare providers

– Level II• National Codes• Products, services and supplies• Current Dental Terminology (CDT)



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ANA Recommended Standardized Nursing Terminologies

• North American Nursing Diagnosis Association (NANDA)– Organized around 13 domains– Contains nursing diagnoses for existing or

potential problems

Source: (Thede, 2011)



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• Nursing Intervention Classification (NIC)– Identifies therapy for the nursing diagnosis

• Nursing Outcomes Classification (NOC)– Describes the patient outcomes associated

with the intervention

Source: (Center for Nursing Classification)



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• Perioperative Nursing Data Set (PNDS)– Standardized, universal language– Developed by Association of periOperative

Registered Nurses (AORN) – Identifies perioperative experience of the patient

from preadmission through recovery at home– Includes nursing diagnoses, interventions and

outcomesSource: (Center for Nursing Classification)



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Recommendations of the National Committee on

Vital and Health Statistics• Health Level 7 (HL7) for

– Messaging– Clinical encounters

• SNOMED CT for– Diagnosis and problem list– Non-laboratory procedures and interventions– Anatomy and nursing data



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Systematized Nomenclature of Medicine Clinical Terms (SNOMED

CT)• Developed by College of American Pathologists• Ownership transferred to International Health

Terminology Standards Development Organisation (IHTSDO)

• Distributed free in the US by NLM

Source: (International Health Terminology Standards Development Organization)



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SNOMED CT

• Compilation of many healthcare terminologies• Comprehensive clinical terminology• Controlled medical terminology• Multilingual• Hierarchical• Captures clinical information in EHR




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Logical Observation Identifiers, Names, and Codes

• Developed by the Regenstrief Institute• Provides a standard set of codes and names for

the electronic reporting of laboratory results • Expanded to include items related to

measurement of clinical observations, such as blood pressure and symptoms




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Consolidated Health Informatics (CHI) Initiative

• CHI is a government initiative– Adopts standards for electronic exchange of

health information– Applies to government healthcare– Includes LOINC, DICOM, SNOMED and

HIPAA code sets

Source: (Consolidated health informatics)



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Summary• Define terms related to standardized

terminologies• Identify and define HIPAA standard code sets• Identify and define terminologies and

vocabularies that represent nursing care• Define and give examples of data interchange

standards



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ReferencesReferences•Amatayakul MK. Electronic health records: a practical guide for professionals and organizations. Chicago (IL): AHIMA; 2009.• American Medical Association. Current procedural terminology (CPT). 4 th edition. Chicago (IL): American Medical

Association; 2011.•Centers for Medicare and Medicaid Services. Overview of HIPAA. US Department of Health and Human Services. Available from: http://www.cms.gov/HIPAAGenInfo/•Center for Nursing Classification [Internet]. Available from: http://ncvhs.hhs.gov/970416w6.htm• Consolidated health informatics (CHI). Office of the National Coordinator. United States Department of Health

and Human Services [Internet]. Available from: http://www.hhs.gov/healthit/chi.html•Giannangelo K, editor. Healthcare code sets, clinical terminologies, and classifications. 2 nd edition. Chicago (IL): AHIMA; 2010.• Health Level Seven International. About HL7. [Internet]. Ann Arbor (MI). Available from:

http://www.hl7.org/about/index.cfm?ref=nav• International Health Terminology Standards Development Organization [Internet]. About SNOMED. Available

from: http://www.ihtsdo.org/snomed-ct/• National Alliance for Health Information Technology. Report to the Office of the National Coordinator for Health

Information Technology on defining key health information technology terms. The National Alliance for Health Information Technology. 2008 Apr 28. p. 10.



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ReferencesReferences•Nightingale F. Notes on hospitals. London: Longman, Green, Longman, Roberts, and Green; 1863. Available from: http://pds.lib.harvard.edu/pds/view/7024419?n=208• Thede L, Schwiran P. Informatics: the standardized nursing terminologies: a national survey of nurses’

experiences and attitudes. OJIN: The Online Journal of Issues in Nursing [Internet]. 2011 Feb 25;16(2). Available from: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No2-May-2011/Standardized-Nursing-Terminologies.aspx

• US Food and Drug Administration [Internet]. Silver Springs (MD): 2012. Protecting and Promoting Your Health. National Drug Code Directory. Available from: http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

ImagesSlides 3, 10, 19: Microsoft Clip Art, Used with Permission of Microsoft.



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