Standards are critical components in the development and implementation of an electronic health record (HER). The effectiveness of healthcare delivery is dependent on the ability of the clinicians to access critical health information when and where it is needed.
Need for healthcare data standards
Data standards as applied to healthcare include:
Methods Protocols Terminologies Specification for the collection Exchange Storage Retrieval of information associated with healthcare applications (medical records, medications, radiological images, payments and reimbursement, medical devices, monitoring system and administrative process)Terminologies
There have been great advances in the ability of the computers to process natural language, most communication between health information systems relies on the use of structured vocabularies, code sets, and classification systems represent healthcare concepts.
Standardized terminologies enable data collection at the point of care, and retrieval of data, information, and knowledge in support of clinical practice.
International statistical classification of diseases and related health problems: 9th revision and clinical modifications
>is the latest version of a mortality and morbidity classification that originated in 1893
>widely accepted, used in the healthcare industry and has been adopted for a number of purposes
l Data collection
l Quality of care analysis
l Resource utilization
l Statistical reporting
>it is the basis for diagnostic related group which are use extensively for hospital reimbursement.
>internationally used for death tabulation
International statistical classification of diseases and related health problems:10th revision
-is the most recent revision of the ICD classification system for mortality and morbidity which is used worldwide
Current procedural terminology. 4th revision
Is a listing of descriptive terms and codes for reporting medical services and procedures. In addition to descriptive terms and codes, it contains modifiers, notes and guidelines to facilitate correct usage.Systematized Nomenclature of Human Veterinary Medicine International, Clinical terms
> (SNOMED) comprehensive multiracial nomenclature and classification system for indexing human and veterinary medical vocabulary, including signs and symptoms, diagnoses and procedures.
LOINC or logical observation identifiers names and codes
-provide a set of universal names and numeric identifier codes for laboratory and clinical observations and measurements in a data base structure
-represents laboratory data in terms of names for tests and clinical observations
-it is clear that such consistency in terminology is important for patient safety
RxNorm
Is a clinical drug nomenclature produced by NLM in consultation with:
q (FDA) food and drug administration
q (VA) department of veterans affairs
q RxNorms provides standard names for clinical drugs (active ingredient+ strength+dose form) and for those forms as administered.
q It provide links from clinical drugs to their active ingredients, drug component (active ingredient+strength) and some related brand names.
Unified Medical Language System
> (UMLS) consist of metathesaurus of terms and concepts from dozen of vocabularies: a semantic network of relationships among the concepts recognize in the metathesaurus: and an information sources map of the various biomedical database referenced.
National Uniform Claim Committee Recommended Data Set for a Noninstitutional Claim
>promote and maintain a standard data set for use of noninstitutional claims and encounter information
A new work item being proposed by the E31 subcommittee is the continuity of care record (CCR)
Continuity of care record is a core data set of the most relevant and timely facts about a patient’s healthcare.
>includes summary of the patients health status and basic information about insurance, advance directives, care documentation and care plan recommendations.
IHE or integrating the healthcare enterprise
Ø Is an initiative that provide detailed framework for implementing standards and their implementation.
Ø It is increasingly recognize that combining the strength of these initiatives and their approaches tends to minimize their weaknesses and can lead to significant gains for the healthcare sector as a whole.
International Organization of standardization
(ISO) Is an organization that develops and publishes standard internationally.
Integration of reference Terminology Model for Nursing
>this standard includes the development of reference terminology models for nursing diagnosis and nursing actions and relevant terminology and definitions for its implementation.
American National Standard Institute
>ANSI serves as the coordinator for voluntary standards activity in the U.S
>also the U.S representative to ISO and is responsible for bringing forward U.S standards to that organization.
Object Management Group
> (OMG) is representative of different approach to standard development.
>is an international consortium of over 800 organizations, primarily for profit vendors of information system technology, who are interested in the development of standard based on object oriented technologies.
National Committee on Vital and Health Statistics Subcommittees on standards and security
Form CPR workgroup. >this workgroup develops recommendations based on public hearings and input from input staked holders and domain experts.
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