1. Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved. McGraw-Hill/Irwin Chapter 2 Clinical Information Standards – Unit 3 seminar Electronic Health Records for Allied Health Careers Cover goes here when ready

2. 2-2 Learning Outcomes After studying this chapter, you should be able to: Discuss why the adoption of clinical standards is critical to the successful implementation of electronic health records. Describe the difference between clinical vocabularies and classification systems. List four messaging standards used with electronic health records. Describe the significance of the Medicare Prescription Drug and Modernization Act of 2003 in the adoption of clinical standards.

3. 2-3 Key Terms classification systems clinical templates clinical vocabularies Current Procedural Terminology (CPT) content standards Digital Imaging and Communications in Medicine (DICOM) Healthcare Common Procedures Coding System (HCPCS), Level II Health Level Seven (HL&) International Classification of Diseases, Ninth Revision and Tenth interoperable Logical Observation Identifiers Names and Codes (LOINC) messaging standards

4. 2-4 Key Terms National Council for Prescription Drug Program (NCPDP) The Institute of Electrical and Engineers1073 (IEEE1073) picture archiving and communication system (PACS) Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) Unified Medical Language System (UMLS)

5. 2-5 The Importance of Clinical Standards What are Clinical Standards? Clinical Standards – Simply put it is the clinical information in a patient record, which must be recorded in standard ways so its meaning can be shared among individuals and organizations in the health care system.

6. 2-6 Interoperable A new word for your vocabulary- Interoperable Interoperable systems that can exchange information and use the information in a meaningful way. Please go to the web site below and locate the article HIT Policy and Standards Committee Commence Work on National Health Information Infrastructure. What are the six priority areas? http://www.hitsp.org/news.aspx

7. 2-7 What is the Importance of Clinical Standards? For health care information to be useful to different providers in all different settings, different computer systems must be interoperable, that must be able to exchange information and use the information in a meaningful way. Example; (page 54) One doctor will use MI to indicate myocardial infraction and another might use the diagnosis code of 410.00. A computer would not know that these two are the same.

8. 2-8 How to solve the problem To solve this problem, a set of common clinical standards must be used b all providers and institutions that contribute information to a patient’s record. No mandatory standards have been adopted for clinical information. Lets watch the following video – University of Mass http://www.youtube.com/watch?v=tUwm4zZxNy0

9. 2-9 Clinical Vocabularies To share the clinical information, clinical vocabularies also known as nomenclatures, common definitions of medical terms, are needed, which provide common medical language. Messaging standards enable computer systems to exchange information with one another. Vocabulary standards define the terms and codes used for clinical information.

10. 2-10 Clinical Information Standards Clinical vocabularies that are relevant to electronic health records: –Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) – page 56, comprehensive clinical vocabulary of all terms used in medicine. http://www.ihtsdo.org/ Logical Observation Identifiers Names and Codes (LOINC) – Universal terms and codes for electronic exchange of laboratory results and clinical observations http://loinc.org/ U.S. National Library of Medicine Unified Medical Language System (UMLS) – Major thesaurus database of medical terms http://www.nlm.nih.gov/research/umls/

11. 2-11 Clinical Information Standards Classification systems – Organize related terms into categories –International Classification of Diseases, Ninth Revision (ICD-9) – Diagnosis codes that are used in all heath care settings, including physician offices, hospitals, long term care facilities and home health agencies. In the US it is the basis not only for disease and illness classification, but also for establishing medical necessity for health insurance reimbursements.

12. 2-12 Clinical Information Standards –International Classification of Diseases, Tenth Revision (ICD-10) In 1993 the WHO, World Health Organization, released ICD-10 to replace ICD-9. The US currently uses it only for coding death certificates. Gradual transition will take place over the next decade.

13. 2-13 Clinical Information Standards –Current Procedural Terminology (CPT) – developed and maintained by American Medical Association is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers in outpatient settings.

14. 2-14 Clinical Information Standards –Healthcare Common Procedures Coding System (HCPCS), Level II classification codes for products, supplies, and certain services not included in the Current Procedural Terminology (CPT)

15. 2-15 Clinical Information Standards Messaging Standards – In addition to clinical vocabularies and classification systems, messaging standards, which allows data transfer to an electronic health record system, plays a crucial role in providing interoperability among information systems. Make it possible to transfer data from systems such as laboratory or pharmacy systems to an electronic health record system. Examples are as follows:

16. 2-16 Clinical Information Systems –Health Level Seven (HL7) used to send data from one application to another such as a laboratory system –Digital Imaging and Communications in Medicine (DICOM) enables information exchange between imaging systems. –Picture Archiving and Communication System (PACS) –National Council for Prescription Drug Program (NCPDP) for exchanging prescription information –The Institute of Electrical and Electronics Engineers 1073 (IEEE1073) provides communication among medical devices at a patient’s bedside, such as cardiac monitors.

17. 2-17 Clinical Information Standards EHR Content Standards –Electronic Health Record System Functional Model (EHR-S-FM) This standard that has been approved by the American National Standards Institute (ANSI) lists critical features and functions contained in an electronic health record system.

18. 2-18 Voluntary Versus Mandatory Systems ICD-9 and CPT classification was first mandated by the Centers for Medicare and Medicaid Services (CMS) for use in medical billing and insurance claims. HIPAA code set standards when the law was passed in 1996 for electronic billing and claims. The Medicare Prescription Drug and Modernization Act of 2003 mandated the use of clinical vocabularies and messaging standards in federal agencies. Selected by the Consolidated Health Informatics Initiative (CHI) the standards must be used by all federal agencies, such as Department of Health and Human Services (HHS) Dept of Veterans Affairs, The Department of Defense and the Social Security Administration.

19. 2-19 Field Trips Here are two videos that discuss health information exchange. http://www.youtube.com/watch?v=JIgKCcBhXjQ http://www.youtube.com/watch?v=Pru4wFrPCOg