Scribd
Upload
29 views

Terminology in Healthcare and Public Health Settings: Standards To Promote Health Information Exchange

The Health IT Workforce Curriculum was developed for U.S. community colleges to enhance workforce training programmes in health information technology. The curriculum consist of 20 courses of 3 credits each. Each course includes instructor manuals, learning objectives, syllabi, video lectures with accompanying transcripts and slides, exercises, and assessments. The materials were authored by Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University, and University of Alabama at Birmingham. The project was funded by the U.S. Office of the National Coordinator for Health Information Technology. All of the course materials are available under a Creative Commons Attribution Noncommercial ShareAlike (CC BY NC SA) License. The course description, learning objectives, author information, and other details may be found at http://archive.org/details/HealthITWorkforce-Comp03Unit16. The full collection may be browsed at http://knowledge.amia.org/onc-ntdc or at http://www.merlot.org/merlot/viewPortfolio.htm?id=842513.

Uploaded by

Health IT Workforce Curriculum - 2012
Copyright
© © All Rights Reserved
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
29 views

Terminology in Healthcare and Public Health Settings: Standards To Promote Health Information Exchange

The Health IT Workforce Curriculum was developed for U.S. community colleges to enhance workforce training programmes in health information technology. The curriculum consist of 20 courses of 3 credits each. Each course includes instructor manuals, learning objectives, syllabi, video lectures with accompanying transcripts and slides, exercises, and assessments. The materials were authored by Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University, and University of Alabama at Birmingham. The project was funded by the U.S. Office of the National Coordinator for Health Information Technology. All of the course materials are available under a Creative Commons Attribution Noncommercial ShareAlike (CC BY NC SA) License. The course description, learning objectives, author information, and other details may be found at http://archive.org/details/HealthITWorkforce-Comp03Unit16. The full collection may be browsed at http://knowledge.amia.org/onc-ntdc or at http://www.merlot.org/merlot/viewPortfolio.htm?id=842513.

Uploaded by

Health IT Workforce Curriculum - 2012
Copyright
© © All Rights Reserved
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
You are on page 1/ 32

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 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
Health 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)
3
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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 information
Source: (Giannangelo, 2010)
4
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Interoperability
Standardized terminologies/ ontologies
Patient diagnoses, interventions, outcomes
Semantic Interoperability
Data means same thing to different users
7
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
EHR Messaging Standards
Also called
Data exchange standards
Interoperability standards
Supports sharing of data
Safe
Accurate
Protocols
Data definitions
Source: (Amatayakul, 2009)
8
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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)




Source: (Amatayakul, 2009)
9
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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 IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Classifications, Terminologies
and Vocabularies
Classification systems
Group similar or related data
Example: ICD-9-CM





Source: (Giannangelo, 2010)
12
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Classifications, Terminologies
and Vocabularies
Classification systems
Group similar or related data
Terminologies
Contain terms that represent a system of
concepts



Source: (Giannangelo, 2010)
13
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Classifications, Terminologies
and Vocabularies
Classification systems
Group similar or related data
Terminologies
Terms that represent a system of concepts
Vocabularies
List or collection of words and their
meanings

Source: (Amatayakul, 2009)
14
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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 IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Health Information Standards
HIPAA national policy
NCVHS recommendations
National Library of Medicine
Unified Medical Language System (UMLS)







Sources: (CMS)
(Giannangelo, 2010)
16
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
HIPAA Standard Code Sets
HIPAA standard code sets
International Classification of Diseases, 9
th
Revision,
Clinical Modification (ICD-9-CM)
National Drug Codes (NDC)
The CMS Healthcare Common Procedure Coding
System (HCPCS)
Current Procedural Terminology, 4
th
edition (CPT)
Code on Dental Procedures and Nomenclature (CDT)
17
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
International Classification of Diseases,
9
th
Revision, Clinical Modification
(ICD-9-CM)
Modification of the World Health Organizations
ICD-9
ICD-10-CM to be implemented in 2014
Numerous purposes
Statistics and research
Reimbursement
Analyzing patterns of care
Strategic planning
18
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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 purposes
Source: (US FDA, 2012)
19
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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)
20
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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)
21
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
ANA Recommended Standardized
Nursing Terminologies
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
ANA Recommended Standardized
Nursing Terminologies
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
25
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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)
26
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
SNOMED CT
Compilation of many healthcare terminologies
Comprehensive clinical terminology
Controlled medical terminology
Multilingual
Hierarchical
Captures clinical information in EHR


Source: (Giannangelo, 2010)
27
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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)
29
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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
30
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
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). 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.
31
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Standards to Promote Health
Information Exchange
References
References
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

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


32
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange

You might also like