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 Organization’s ICD-9 ICD-10-CM to be implemented in 2013 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; American Medical Association. Current procedural terminology (CPT). 4 th edition. Chicago (IL): American Medical Association; Centers for Medicare and Medicaid Services. Overview of HIPAA. US Department of Health and Human Services. Available from: Center for Nursing Classification [Internet]. Available from: Consolidated health informatics (CHI). Office of the National Coordinator. United States Department of Health and Human Services [Internet]. Available from: Giannangelo K, editor. Healthcare code sets, clinical terminologies, and classifications. 2 nd edition. Chicago (IL): AHIMA; Health Level Seven International. About HL7. [Internet]. Ann Arbor (MI). Available from: International Health Terminology Standards Development Organization [Internet]. About SNOMED. Available from: 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 Apr 28. p 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; Available from: 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] Feb 25;16(2). Available from: /No2-May-2011/Standardized-Nursing-Terminologies.aspx /No2-May-2011/Standardized-Nursing-Terminologies.aspx US Food and Drug Administration [Internet]. Silver Springs (MD): Protecting and Promoting Your Health. National Drug Code Directory. Available from: 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