Terminology in Healthcare and Public Health Settings
This material covers standards promoting health information exchange, including defining terms, HIPAA codes, nursing care vocabularies, data interchange standards, data collection, data elements, metadata, and interoperability in healthcare. It emphasizes the significance of standardized terminologies and the need for accurate data exchange for effective healthcare practices.
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Terminology in Healthcare and Public Health Settings Standards to Promote Health Information Exchange This material (Comp 3 Unit 14) was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org.
Standards to Promote Health Information Exchange Learning 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 2
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) 3
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 information Source: (Giannangelo, 2010) 4
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) 5
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) 6
Interoperability (cont) Standardized terminologies / ontologies Patient diagnoses, interventions, outcomes Semantic Interoperability Data means same thing to different users 7
EHR Messaging Standards Also called Data exchange standards Interoperability standards Supports sharing of data Safe Accurate Protocols Data definitions Source: (Amatayakul, 2009) 8
EHR Messaging Standards (cont) Numerous standards, including American National Standards Institute, Accredited Standards Committee X12- Insurance Subcommittee (ANSI-ASCX12N) Digital Imaging and Communications in Medicine (DICOM) Source: (Amatayakul, 2009) 9
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) 10
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) 11
Classifications, Terminologies and Vocabularies Classification systems Group similar or related data o ICD-10-CM o ICD-10-PCS Source: (Giannangelo, 2010) 12
Classifications, Terminologies and Vocabularies (2) Terminologies Contain terms that represent a system of concepts Source: (Giannangelo, 2010) 13
Classifications, Terminologies and Vocabularies (3) Vocabularies List or collection of words and their meanings Source: (Amatayakul, 2009) 14
Clinical Terminologies Designed for the documentation by providers when delivering clinical care Allow for the information to be codified and used in EHRs 15
Health Information Standards HIPAA national policy NCVHS recommendations National Library of Medicine Unified Medical Language System (UMLS) Sources: (CMS) (Giannangelo, 2010) 16
HIPAA Standard Code Sets HIPAA standard code sets International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) National Drug Codes (NDC) The CMS Healthcare Common Procedure Coding System (HCPCS) o Current Procedural Terminology, 4th edition (CPT) o Code on Dental Procedures and Nomenclature (CDT) 17
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Modification of the World Health Organization s ICD-10 ICD-10-CM implemented in 2015 Numerous purposes Statistics and research Reimbursement Analyzing patterns of care Strategic planning 18
National Drug Codes (NDC) Used for reporting retail pharmacy transactions Owned by the US FDA Medications o Prescription drugs o Over-the-counter (OTC) drugs o Drugs used by veterinarians Used for billing and reimbursement Used for tracking drugs for many purposes Source: (US FDA, 2012) 19
Healthcare Common Procedure Coding System (HCPCS) HIPAA standard code set Level I o Current Procedural Terminology (CPT) codes o Medical services and procedures performed by physicians and other healthcare providers Source: (American Medical Association, 2011) 20
Healthcare Common Procedure Coding System (HCPCS) (con t) HIPAA standard code set Level II o National Codes o Products, services and supplies o Current Dental Terminology (CDT) 21
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) 22
ANA Recommended Standardized Nursing Terminologies (2) 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) 23
ANA Recommended Standardized Nursing Terminologies (3) 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 outcomes Source: (Center for Nursing Classification) 24
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 25
Systematized Nomenclature of Medicine Clinical Terms 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) 26
SNOMED CT Compilation of many healthcare terminologies Comprehensive clinical terminology Controlled medical terminology Multilingual Hierarchical Captures clinical information in EHR Source: (Giannangelo, 2010) 27
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 Source: (Giannangelo, 2010) 28
Standards to Promote Health Information Exchange 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 29
Standards to Promote Health Information Exchange References References Amatayakul MK. Electronic health records: a practical guide for professionals and organizations. Chicago (IL): AHIMA; 2009. American Medical Association. Current procedural terminology (CPT). 4th 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 Center for Nursing Classification [Internet]. Available from: http://www.nanda.org/ 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. 2nd edition. Chicago (IL): AHIMA; 2010. Health Level Seven International. About HL7. [Internet]. Ann Arbor (MI). Available from: http://www.hl7.org International Health Terminology Standards Development Organization [Internet]. About SNOMED. Available from: http://www.ihtsdo.org/snomed-ct/ 30
Standards to Promote Health Information Exchange References (con t) References 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. Nightingale F. Notes on hospitals. London: Longman, Green, Longman, Roberts, and Green; 1863. Available from: http://pds.lib.harvard.edu 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 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 Images Slides 3, 10, 19: Microsoft Clip Art, Used with Permission of Microsoft. 31
Terminology in Healthcare and Public Health Settings, Standards to Promote Health Information Exchange This material was developed by The University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007.
