1. Data and Interoperability:
Health Informatics in Low- and Middle-Income Countries
Short Course for Health Information System Professionals
Data and Interoperability:
Standards to Promote Health Information Exchange

2. Standards to Promote Health Information Exchange Learning Objectives
Define terms related to standardized terminologies
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. The Problem Understanding what the data say
Understanding what the data mean
Understanding where the data are
Understanding the context in which the data are collected
Failure to understand may result in a medical error and maybe even death
A fundamental problem has existed in storing and sharing health data electronically. That problem is the lack of a standard set of data elements unambiguously defined with a common set of attributes, particularly the name or terminology of the data element or item. Even within a single institution, data cannot be aggregated easily. The HIT community has been reluctant to address this problem for many reasons including economic pressures not to change, indecisions about what is the solution, inability to agree on terms and processes, and the lack of a decision-body with sufficient clout to make it happen.
The problems are:
We all speak a different language:
One institution had a project to create an institution-wide registry for patients with diabetes. They were unable to do so because of the absence of a common vocabulary. The Joint Commission, which collects data from all hospitals, cannot do an analysis on an aggregated data set because of the absence of semantic interoperability. They analyze subsets of the data and merge the analyses.
Understanding what the data says
When you say heart attack and I say MI, are we talking about the same thing?
What do you mean by angina? Is that what the patient has when she says “I have chest pain”?
Understanding what the data means
When you say elevated blood sugar, are you using the same metric as I?
In a study in 2000, one researcher identified over 60 different definitions for unstable angina through a study of the literature.
Understanding where the data is in the electronic record.
Data frequently cannot be found in EHRs although it does exist at some place in the record.
Depending on the test, the same data element may be stored in different places in the record as a component of the different test. We don’t define the degree of granularity at which we store the data.
Understanding the context in which the data is collected.
Was this lab test just after the patient had eaten?
Most new projects start off with the definition of what is called a Minimum Data Set. The same words are often reinvented every time a new Minimum Data Set is defined. If we misinterpret what a word means, we may make a medical error that results in an aggravation of a patient’s condition or even death.

4. Data Collection
“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.”
Florence Nightingale
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.

5. 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.
(Giannangelo, 2010)

6. 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
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).
(Giannangelo, 2010; Amatayakul, 2009)

7. 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.
(National Alliance for Health Information Technology, 2008)

8. Interoperability Standardized terminologies and ontologies
Patient diagnoses, interventions, outcomes
Semantic interoperability
Data mean 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.

9. Semantic Interoperability
The ability to share data whose meaning is unambiguously clear and precise, their context understood, so they can be used for any purpose. With true semantic interoperability, the receiver is independent from the sender.
Semantic interoperability is the ability to share data whose meaning is unambiguously clear and precise, its context understood, and it can be used for any purpose. With true semantic interoperability, the receiver may be totally independent from the sender or even unknown to the sender. The receiver does not need to have previous understanding with what will be exchanged and how.
Additionally, we need to know how to package the data that is shared so that receiver understands the context of the data and its relationship to other data.

10. Problems Preventing Semantic Interoperability
There are many problems that prevent us from achieving semantic interoperability.
Same words that have different meanings
Different words that have the same meaning
Words that are too general to convey a specific meaning
Localisms that lose meaning beyond that region
Failure to pay attention to factors other than name, such as units or how measured
Inconsistencies in the level at which things are described
There are many problems that prevent us from achieving semantic interoperability.
Same words that have different meanings.
Different words that have the same meaning.
Words that are too general to convey a specific meaning.
Localisms that lose meaning beyond that region.
Failure to pay attention to factors other than name, such as units or how measured.
Inconsistencies in the level at which things are described.
Here are some examples that make these points.
Do you say sex or gender? When you ask do you smoke, what do you mean – now, last month, last year, last 5 years, or ever?
Do you record male, man or boy? Humans recognize the distinction, but does a computer unless it has been taught?
Heart attack vs chronic heart failure vs myocardial infarction. Moderately vs severe, congested, restricted.
Chest pain is a symptom that can have many causes.
Consider local and cultural terms - What is bad blood? Is hbp the same as high blood pressure is the same as hypertension is the same as essential hypertension is the same as benign hypertension? Is the distinction important? Which are synonyms and which are, in fact, different terms?
What does fever mean to you, or a high fever? What do you mean by weak? How evidenced?
Do you measure height with the shoes removed? Do you remove coats and sweaters when you measure weight? What is the patient’s position when you measure the blood pressure? What has the patient been doing prior to the measurement? Who made the measurement and how?

11. Semantic Interoperability: Issues
Legacy of existing data
More than 400 terminologies in use today, plus local vocabularies
Lack of a solution = no semantic interoperability
What do we do with all the data that currently has been collected? Do we throw it away, or do we try to convert it to the new data elements?
Semantic interoperability requires many different parameters to be addressed. For example, consider the term itself. How specific is the word that is used? How precise is the meaning? One person may say heart attack which is a highly generic term covering a lot of specific problems. Someone else may say myocardial infarction; another may say heart failure. Are these the same? Units must match or at least be known. Is the weight expressed in pounds or is the weight in kilograms? For compound data items such as the results from a pap smear, what is the structure of the result reporting? How can you find the pieces you want?
Fundamentally, there is no standard vocabulary in use for health care today. Most legacy systems are unstructured, undefined, uncontrolled narrative or free text.
Photo courtesy of Dr. Betsy Humphreys of the National Library of Medicine

12. More Problems There are too many choices for too many purposes.
Certain “words” are required for specific uses, but these choices do not satisfy multiple uses.
Most institutions use local vocabularies and map to the broader set of controlled vocabularies they are required to use.
Many groups are dealing independently with some terminology and data elements; no group is dealing with all. Too many solutions are no solutions at all.
Many terminologies exist, but all fail to meet all the requirements. Do we try to fix what is, or do we make a new approach?
Most institutions today are not willing to commit to changing from a local terminology to a standard set of data elements because of the costs, and until a decision is made nationally that will be sustained.
Until we commit to a solution, we will use work-arounds that do not solve the problem. Most work-arounds cost money, cause a loss of information, and are never up-to-date. Those work-arounds usually involve mapping from one terminology set to another.

13. Confusion Comes Quickly
Vocabulary
Terminology
Nomenclature
Classification
Taxonomy
Ontology
Groupers
The confusion begins when we try to identify what we are talking about. Different coding systems are classified in one of these categories. Does it matter? These are the different words you will hear when talking about “data elements”. All of these words sort of mean the same thing but are different. For the purposes of this lecture, we use the words interchangeably, with data element as the root word.
A Vocabulary is a set of words used to express a concept or thought. It means that some organization has placed some constraints and organization on the set of words and manage content. It is an organized list of words and phrases used to tag content. Examples include Logical Observation Identifier Names and Codes (LOINC).
A Terminology is considered by most to be a synonym of vocabulary. It is a system of specialized terms and a symbolic representation of conceptual information. It is a finite, enumerated set of terms intended to convey information unambiguously. It is a body of terms assigned to or used for a particular type of thing. A terminology is essential for proper data storage and retrieval and requires an internationally recognized nomenclature of diseases, pathology, clinical indicants, treatments and surgical operations.
A Nomenclature refers to a system of names or terms used in a particular science or art. It is a consistent, systematic method of naming to denote classifications and avoid ambiguities. Names of anatomical structures or organs of the body are usually referred to as a nomenclature. An example is SNOMED.
A Classification is a grouping of objects into a class or classes according to some common relations or attributes. Examples are International Classification of Diseases (ICD 9 or ICD 10) and International Classification for Primary Care (ICPC).
A Taxonomy is the practice and science of classification. Taxonomies are typically arranged in a hierarchical structure and exhibit parent-child relationships.
An Ontology consists of basic categories of being and their relations; it deals with questions concerning what entities exist or can be said to exist, how such entities can be grouped, related within a hierarchy and subdivided according to similarities and differences. An ontology is a formal representation of a set of concepts within a domain and the relationships between those concepts.
A Grouper groups together diagnoses and procedures that are similar resources used for billing purposes. An example is DRG.

14. Basic Features of Terminology
Basic features of terminology include:
Unique identifier—code
Numeric and without meaning
May include check digit
Moving toward use of International Organization for Standardization-based object identifier (paths in a tree structure)
Assigning authority is assigned to organizations who in turn assign the identifiers (Health Level 7 is an assigning authority)
Official name
Female
Synonyms
Woman, girl
Basic features of terminology include:
A Unique Identifier – code that has these characteristics:
Numeric and without meaning;
May include check digit;
Moving toward use of ISO-based Object Identifier called OIDs (paths in a tree structure);
Assigning authority is assigned to organizations who in turn assign the identifiers; HL7 is an assigning authority.
Official Name. An example is Female
Terminology may have synonyms, such as woman or girl for female.
Codes have the value of being absolute, precise and unambiguous. If codes are what we exchange, we cannot misinterpret. We can further relate the code with a set of attributes or characteristics - as a preferred name or a synonym. We can express the name and concept of the data element in any language. The code might include a check digit for detecting entry errors.
The coding system needs to be universal. The movement for assigning codes in the future is toward using ISO Object Identifiers (OIDs). However, most vocabularies in use today already have a coding system. These coding systems are unique to the controlled vocabulary. In many cases, the codes attempt to carry information in their format and structure. For example, the code shows the body system involved, or the code shows linkages or the code relates to the name such as m = male.

15. General Categories of Terms
Demographics
Diagnoses
Signs and symptoms
Medications
Anatomy
Allergies
Physical findings
Therapeutic procedures
Diagnostic procedures
Adverse events
Organisms
Genomics
It is useful to assign data elements to classes or categories. Most systems would use categories similar to these:
Demographics
Signs and symptoms
Anatomy
Physical findings
Diagnostic procedures
Organisms
Diagnoses
Medications
Allergies
Therapeutic procedures
Adverse events
Genomics
In some cases, a coding system will only include terms in some of these categories. If we depend on just one coding system, we have data items we cannot code. Of course everything we record does not fit into these categories – then what do we do?

16. Coding the Data—Gender
Data element—gender
Class: demographic
Controlled terminology (value set)
Male
Female
Unknown (don’t know, haven’t asked)
Unknown (can’t tell) (by dress; anatomically)
Representation
M,F,U or 0,1,2 or other
Administrative or clinical
Let’s take a look at a specific data element—gender—and see how complicated even a simple data element might be. How many values might the answer to this question have?
What is administrative gender? What happens if we are talking about clinical gender? How do we distinguish gender if we are talking about X and Y chromosomes? What if we can’t determine gender? Note the distinction in the two unknowns—which does just unknown mean? Is this definition sufficient?
An obvious answer to the gender question might be two—male and female. But what if we are talking about gender from a clinical perspective. Some terminologies have as many as 27 different values for this term. Several terminologies break gender into two terms. The first is administrative gender and the second is clinical gender.
How do we represent the values that may be assigned to gender. Classically, we have used letters, names, and numbers as possible values among the different users.

17. Electronic Health Record Messaging Standards
Also called
Data exchange standards
Interoperability standards
Support 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.
(Amatayakul, 2009)

18. Electronic Health Record Messaging Standards
Numerous standards, including
American National Standards Institute (ANSI), Accredited Standards Committee X12-Insurance Subcommittee
Digital Imaging and Communications in Medicine
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.
(Amatayakul, 2009)

19. Digital Imaging Communications in Medicine
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, and so forth.
(Giannangelo, 2010)

20. Health Level 7 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.
(Health Level Seven International)

21. Classifications, Terminologies and Vocabularies
Classification systems designed to group similar or related data
Group similar or related data
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
International Classification of Diseases, 10th Revision, Procedure Coding System (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.
(Giannangelo, 2010)

22. Classifications, Terminologies and Vocabularies
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.
(Giannangelo, 2010)

23. Classifications, Terminologies and Vocabularies
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.
(Amatayakul, 2009)

24. Clinical Terminologies
Designed for the documentation by providers when delivering clinical care
Allow for the information to be codified and used in electronic health records (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.

25. 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.

26. National Drug Codes Used for reporting retail pharmacy transactions
Owned by the U.S. Food and Drug Administration
Medications
Prescription drugs
Over-the-counter 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.
(U.S. Food and Drug Administration, 2012)

27. National Committee on Vital and Health Statistics
Health Level 7 for:
Messaging
Clinical encounters
Systematized Nomenclature of Medicine, Clinical Terminology (SNOMED CT) for:
Diagnosis and problem list
Nonlaboratory 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.

28. Systematized Nomenclature of Medicine Clinical Terms
Developed by College of American Pathologists
Ownership transferred to International Health Terminology Standards Development Organisation
Distributed free in the United States by the National Library of Medicine
The Systematized Nomenclature of Medicine (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.
(International Health Terminology Standards Development Organization)

29. 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)

30. 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.
(Giannangelo, 2010)

31. Standards to Promote Health Information Exchange Summary
Define terms related to standardized terminologies
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 standard 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.

32. Standards to Promote Health Information Exchange References
Amatayakul, M.K. (2009). Electronic health records: A practical guide for professionals and organizations. Chicago, IL: American Home Information Management Association.
American Medical Association. (2011). Current procedural terminology (CPT). 4th edition. Chicago, IL: American Medical Association.
Centers for Medicare and Medicaid Services. Overview of HIPAA. U.S. Department of Health and Human Services. Retrieved from:
Giannangelo K. (Ed.). (2010. Healthcare code sets, clinical terminologies, and classifications. 2nd edition. Chicago, IL: American Home Information Management Association.
Health Level Seven International. About HL7. Retrieved from
International Health Terminology Standards Development Organization. About SNOMED. Retrieved from
International Nursing Knowledge Association. (n.d.). Center for nursing classification. Retrieved from
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33. Standards to Promote Health Information Exchange References
National Alliance for Health Information Technology. (2008). Report to the Office of the National Coordinator for Health Information Technology on defining key health information technology terms (p. 10). Chicago, IL: Healthcare Information and Management Systems Society.
Nightingale, F. (1863). Notes on hospitals. London, UK: Longman, Green, Longman, Roberts, and Green; Retrieved from
Thede, L., & Schwiran, P. (2011). Informatics: the standardized nursing terminologies: a national survey of  nurses’ experiences and attitudes. The Online Journal of Issues in Nursing,16(2).
U.S. Department of Health and Human Services, Office of the National Coordinator. Consolidated health informatics. Retrieved from:
U.S. Food and Drug Administration. (n.d.). National drug code directory. Retrieved from
Images
Microsoft Clip Art, Used with Permission of Microsoft.
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34. 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.
This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government.