1. Terminology in Healthcare and Public Health Settings
Standards to Promote Health Information Exchange
Welcome to Terminology in Healthcare and Public Health Settings, Standards to Promote Health Information Exchange. In this unit we will discuss some of the standard clinical vocabularies and terminologies that are needed to exchange health information across providers.
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.
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2. 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
The objectives for this unit, Standards to Promote Health Information Exchange, are to define terminology related to standardized data sets, to identify and define the HIPAA standard data sets, to identify and define the terminologies and vocabularies that represent nursing care, and to define and give examples of the data interchange standards.

3. 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.”
Before we look at data collection in modern terms, let’s take a look at what Florence Nightingale thought about hospital records in the middle of the nineteenth century: “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.”
The collection of data in healthcare has improved since Nightingale made this statement in However, we still collect data in such a way that it cannot be compared across systems. To compare data we need to have standard definitions.
Source: (Nightingale, 1863, p. 176)

4. 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
Using only standardized terminologies or data sets means that data collection and reporting are done in a standardized manner. Here are a few important points about health information standards:
A data set is a list of the data elements with uniform definitions for each element.
Standardized terminologies allow us to merge data so that population health studies can be conducted, decision support can be utilized and mapping between terminologies for patient-specific information can be achieved.
Source: (Giannangelo, 2010)

5. Important Terms Data dictionary Metadata
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
Standardized data sets have a data dictionary that contains the metadata, that is, the data about each data element so that users know what each data element means. For each data element the data dictionary contains information such as the definition, principles and guidelines, the values, format and synonyms. The specification for the values will include how many characters are in the data field and if the characters use letters from the alphabet or numbers or perhaps alpha numeric which would use both numbers and alphabet letters.
In addition to using standardized terminologies so that all users understand what the data mean, different systems need to be able to technically exchange data, for instance, if a hospital wanted to access the data from the records of a patient’s primary care physician. In order to be able to exchange data, the two information systems need to be what is known as interoperable (pronounced inter-operable).
Sources: (Giannangelo, 2010)
(Amatayakul, 2009)

6. 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
According to the National Alliance for Health Information Technology, interoperability (pronounced inter-opper-ability) is defined as “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.” Two key elements of this definition are exchange and use.
For example, to exchange data between systems, data must be formatted in a standard manner. A patient’s birth date may be stated in multiple ways. Even though we can understand these differences, the information systems do not automatically understand these differences in format. For the systems to be interoperable, each system must understand which numbers represent the month, date and year. What is needed are what are called messaging standards.
Source: (National Alliance for Health Information Technology, 2008)

7. Interoperability (con’t)
Standardized terminologies / ontologies
Patient diagnoses, interventions, outcomes
Semantic Interoperability
Data means same thing to different users
Standardized terminologies, also called ontologies (pronounced ont-OLL-uh-jeez) or healthcare system languages, have been designed to describe patient diagnoses, interventions, and outcomes. Standardized terminologies help achieve what is known as semantic (pronounced suh-mantic) interoperability. Semantic refers to “meaning.” Semantic interoperability assures that the terms mean the same thing to different users, and it is this aspect of interoperability that allows the data that are exchanged to be effectively used in clinical care and research.
We will discuss both messaging standards and standardized terminologies in this unit. First, we will discuss messaging standards.

8. EHR Messaging Standards
Also called
Data exchange standards
Interoperability standards
Supports sharing of data
Safe
Accurate
Protocols
Data definitions
Electronic Health Records, or EHRs, should comply with standards that support communications or exchange of data. The messaging standards are also called data exchange standards and sometimes called interoperability (pronounced inter-opp-er-ability) standards. Adhering to the standards supports accurate sharing of data. The various standards have protocols that define the formats for the electronic exchange of data.
Source: (Amatayakul, 2009)

9. EHR Messaging Standards (con’t)
Numerous standards, including
American National Standards Institute, Accredited Standards Committee X12-Insurance Subcommittee (ANSI-ASCX12N)
Digital Imaging and Communications in Medicine (DICOM)
There are numerous messaging standards for EHR exchange of information. The appropriate standard depends on the type of data to be exchanged.
For example, the American National Standards Institute, Accredited Standards Committee X12 (pronounced X-twelve)-Insurance Subcommittee known as ANSI-ASCX12N (pronounced ann-see-A-S-C-X-twelve-N) established standards for exchange of administrative data which includes insurance claims. The standards specify how large the data field should be, whether the field is required or optional and define the specific data elements that go in each field.
The Digital Imaging and Communications in Medicine standards or DICOM (pronounced dye-comm) are used for the exchange and storage of images and diagnostic information.
Source: (Amatayakul, 2009)

10. 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
DICOM standards can be applied in any healthcare setting using diagnostic images such as radiology, pathology, dentistry and surgery. The standards address areas such as data structure, data dictionary, message exchange, media storage, mapping, et cetera.
Source: (Giannangelo, 2010)

11. Health Level 7 (HL7) ANSI accredited SDO
Used for healthcare information exchange around the world
Standards for
Clinical data exchange
Vocabulary
Document architecture
Health Level Seven or HL7 (pronounced H L Seven) is a nonprofit standards development organization or SDO (pronounced S-D-O) that is accredited by ANSI (pronounced Ann-see) and is used around the world for exchange of healthcare data. ANSI is the American National Standards Institute and it is the organization in the US that accredits the SDOs for the various types of standards. The standards include clinical data exchange, standard vocabulary and document architecture which allows for exchanging, integrating and retrieving data that supports healthcare delivery and management. HL7 facilitates the electronic exchange of data within a healthcare organization but also outside the organization.
Now let’s look at some of the standardized terminologies. Before we go into the details of the different systems we need to distinguish between classifications, terminologies and vocabularies.
Source: (Health Level Seven International)

12. Classifications, Terminologies and Vocabularies
Classification systems
Group similar or related data
ICD-10-CM
ICD-10-PCS
Classification systems are designed to group similar or related data. One use of classification systems is for external reporting for a variety of purposes including reimbursement. One example of a classification system is the International Classification of Diseases, Tenth Revision, Clinical Modification, known as ICD-10-CM (pronounced I-C-D-10-C-M) that is used for reporting the principal diagnosis for which a patient is admitted to the hospital and other diagnoses affect care. ICD-10-CM is also used to report the reason the patient is seen in the outpatient setting.   For example, with ICD-10-CM, asthma diagnoses are grouped or classified together under the same category code. The sub-groupings within the category provide further information on the severity of the asthma along with if there was a sudden increase in severity and if the asthma was nonresponsive to initial treatment. Procedures are coded by ICD-10-PCS (pronounced I-C-D-10-P-C-S). PCS stands for Procedure Coding System.
Source: (Giannangelo, 2010)

13. Classifications, Terminologies and Vocabularies (2)
Contain terms that represent a system of concepts
In contrast to a classification, a terminology is a set of terms that represent a system of concepts. For example, in a terminology the term “hyperthermia” ( pronounced hyper-them-ee-uh) would include the concepts of fever, febrile (pronounced FEBB-rile) and elevated temperature.
Source: (Giannangelo, 2010)

14. Classifications, Terminologies and Vocabularies (3)
List or collection of words and their meanings
Vocabularies are lists of words and their meanings, much like a dictionary. It is important to know that while some references define vocabularies as a collection of words with their definitions, others use terminologies and vocabularies as synonyms.
Source: (Amatayakul, 2009)

15. Clinical Terminologies
Designed for the documentation by providers when delivering clinical care
Allow for the information to be codified and used in EHRs
More specifically, clinical terminologies are designed to capture the documentation entered by providers when delivering clinical care. Medical information can be codified (pronounced code-ih-fied) during the course of patient care if these terminologies are incorporated into the EHR (pronounced E-H-R). Codified is when medical information is reduced to or assigned a code. Codes can be a combination of digits or letters of the alphabet or both.

16. Health Information Standards
HIPAA national policy
NCVHS recommendations
National Library of Medicine
Unified Medical Language System (UMLS)
Title II (pronounced two) of the Health Insurance Portability and Accountability Act of 1996 contained standards related to the privacy, security, and electronic transactions and code sets for health information. Some of these health information standards specified terminologies and vocabularies, and code sets to be used by covered entities to make exchange of healthcare information easy. The HIPAA (pronounced HIPP-uh) legislation of 1996 also established policies supporting standards for the EHR. The National Committee for Vital and Health Statistics made recommendations that identified standardized terminologies and vocabularies to be used with the EHR.
In addition within the National Library of Medicine’s Unified Medical Language System there are hundreds of terminologies that are publicly available.
Sources: (CMS)
(Giannangelo, 2010)

17. 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)
Current Procedural Terminology, 4th edition (CPT)
Code on Dental Procedures and Nomenclature (CDT)
Although there are a lot of standard terminologies, HIPAA (pronounced HIPP-Uh) specifies standard code sets for coding diagnoses and procedures. These are the International Classification of Diseases, 10th Revision, Clinical Modification or ICD-10-CM, National Drug Codes, the CMS Healthcare Common Procedure Coding System or HCPCS (pronounced hick-picks) which includes the Current Procedural Terminology, 4th edition known as CPT (pronounced C-P-T), and the Code on Dental Procedures and Nomenclature, which is also referred to as Current Dental Terminology - Dental Code Set or CDT (pronounced C-D-T). We will now discuss each of these code sets.

18. Modification of the World Health Organization’s ICD-10
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
The International Classification of Diseases, 10th Revision, Clinical Modification or ICD-10-CM (pronounced I-C-D-10-C-M) is a HIPAA standard code set. As we mentioned earlier, ICD-10-CM is a classification system because it groups similar conditions together and is hierarchical.
The ICD-10-CM is a modification of the ICD-10 International Classification of Diseases which was published by the World Health Organization or WHO (pronounced W-H-O). The US clinical modification of the ICD-10 was implemented in October 2015.
ICD-10-CM has numerous purposes, including, reimbursement for care, analyzing patterns of care, strategic planning, and monitoring utilization of resources, as well as research and statistical reports on diseases.

19. 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
The National Drug Codes, called NDC (pronounced N-D-C), is a HIPAA standard code set used for reporting retail pharmacy transactions. The NDC is owned by the US Food and Drug Administration or FDA (pronounced F-D-A) and is distributed by the Department of Health and Human Services. The code set identifies the ingredients and other characteristics of prescription drugs, over-the-counter, that is OTC (pronounced O-T-C) drugs, and drugs used by veterinarians. The NDC has numerous uses. One use is to code medications for billing and reimbursement. It is also used when one wants to track the use of drugs for public health protection, track adverse drug events, identify drugs for recall, and evaluation of the effectiveness of drugs used in natural disasters and terrorist threats.
Source: (US FDA, 2012)

20. 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
The Healthcare Common Procedure Coding System known as HCPCS (pronounced hick-picks) is another HIPAA standard code set that is commonly used in the outpatient setting. The coding system is not only used in outpatient settings by healthcare providers and medical suppliers for reimbursement, but also for measuring quality of care and conducting research.
It is composed of two levels. Level I (pronounced one) is called the Current Procedural Terminology or CPT (pronounced C-P-T) codes. CPT contains the codes for services and procedures that physicians and other healthcare providers perform. It is published by the American Medical Association.
Source: (American Medical Association, 2011)

21. Healthcare Common Procedure Coding System (HCPCS) (con’t)
HIPAA standard code set
Level II
National Codes
Products, services and supplies
Current Dental Terminology (CDT)
Level II (pronounced two) codes, called National Codes, identify medical supplies and products used.
For example the level II codes contain codes for portable oxygen tanks. There are also codes for reporting services not included in the CPT codes.
The Current Dental Terminology that is one of the HIPAA standard code sets is in level II. It is used to report dental procedures. Much like CPT, it facilitates communication of accurate information and is the standard for documenting dental procedures. It is published by the American Dental Association.

22. ANA Recommended Standardized Nursing Terminologies
North American Nursing Diagnosis Association (NANDA)
Organized around 13 domains
Contains nursing diagnoses for existing or potential problems
The American Nurses Association recognizes many nursing terminologies; only a few will be discussed here.
The North American Nursing Diagnosis Association, or NANDA (Pronounced NAN-duh) is a classification of nursing diagnoses. It is organized around 13 domains that include nutrition, activity or rest and elimination or exchange. A nursing diagnosis is not a medical diagnosis but an existing or potential problem. For example, a nursing diagnosis might be anxiety or pain.
Source: (Thede, 2011)

23. 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
The Nursing Intervention Classification or NIC (pronounced NICK) is used to identify what the nurse did for the patient to relieve or prevent current or potential problems. NIC contains 433 interventions.
The Nursing Outcomes Classification or NOC (pronounced knock) is a terminology used for the evaluation of the outcome of the nursing interventions. Included with each outcome are the definition and indicators for assessing the effectiveness of the intervention.
Source: (Center for Nursing Classification)

24. 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
The Perioperative Nursing Data Set or PNDS (pronounced PNDS) is a standardized, universal language developed by Perioperative Registered Nurses. It is recognized by the ANA (pronounced A-N-A) as a data set useful for perioperative nursing. Perioperative is the period of time surrounding the surgery from preadmission to discharge of the patient and recovery at home. It includes nursing diagnoses, interventions and nurse-sensitive patient outcomes. For example, an operation outcome is “Permit Signed.”
Source: (Center for Nursing Classification)

25. 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
The National Committee on Vital and Health Statistics has recommended the adoption and use of Health Level 7 (pronounced health level seven) and the Systematized Nomenclature (pronounced NOME-en-clay-ture) of Medicine, Clinical Terminology or SNOMED CT (pronounced snow-med-C-T) in all healthcare information systems. We have already discussed HL7. Now we will discuss SNOMED CT.

26. 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
The Systematized Nomenclature of Medicine called SNOMED was originally developed by the College of American Pathologists and the earliest version dates back to 1974 when they published the Systematized Nomenclature of Pathology called SNOP (pronounced snopp). In 2007, the ownership was transferred to International Health Terminology Standards Development Organization but in the US the National Library of Medicine or NLM (pronounced N-L-M) distributes SNOMED CT. Although there are numerous versions of SNOMED, we will only review SNOMED CT. The CT stands for clinical terminology.
Source: (International Health Terminology Standards Development Organization)

27. SNOMED CT Compilation of many healthcare terminologies
Comprehensive clinical terminology
Controlled medical terminology
Multilingual
Hierarchical
Captures clinical information in EHR
SNOMED is really a compilation of many of the healthcare terminologies organized together in one terminology structure, including commonly used medicine and nursing languages. It is a comprehensive clinical terminology used all over the world and therefore is published in numerous languages. It has information about the disease’s location, structure, etiology (which is the cause of the disease), and the effect of the disease on the patient’s ability to function. SNOMED CT is designed to be used in the EHR to capture the clinical information by assigning codes to terms that represent medical concepts, descriptions of those concepts, and their relationships.
Source: (Giannangelo, 2010)

28. 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
The preferred standardized terminology for representing laboratory data in information systems is LOINC (pronounced loink). LOINC was developed by the Regenstrief (pronounced Ree-gen (like again)-streef) Institute. It not only provides a standard way of representing laboratory data, but it can also be used to represent physiological patient data in a standardized manner.
Source: (Giannangelo, 2010)

29. 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
This concludes Standards to Promote Health Information Exchange. In summary, we have discussed the terms related to standardized terminologies. Since data exchange between interoperable systems requires that data be formatted in a standard manner and that organizations use standard terminologies within the EHR, you should be able to identify and define HIPAA standard code sets and identify and define terminologies and vocabularies that represent nursing care. Finally, you should now be familiar with the numerous standardized healthcare terminologies and data sets that facilitate the exchange and transmission of healthcare data.

30. Standards to Promote Health Information Exchange 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:
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. 2nd edition. Chicago (IL): AHIMA; 2010.
Health Level Seven International. About HL7. [Internet]. Ann Arbor (MI). Available from:
International Health Terminology Standards Development Organization [Internet]. About SNOMED. Available from:
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31. Standards to Promote Health Information Exchange References (con’t)
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. 10.
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:
US Food and Drug Administration [Internet]. Silver Springs (MD): Protecting and Promoting Your Health. National Drug Code Directory. Available from:
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Images
Slides 3, 10, 19: Microsoft Clip Art, Used with Permission of Microsoft.

32. 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.
No audio.