1. Terminology in Health Care and Public Health Settings
Unit 17
Definitions and concepts in the EHR
In this presentation you will learn about how standardizing data can lead to the development of information systems that can exchange data in a meaningful manner.

2. Health IT Workforce Curriculum Version 1.0/Fall 2010
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 1863
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.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

3. Interoperable Systems
Exchange data seamlessly between systems
Must have data coded in a standard format that matches data structures in other systems to accomplish data exchange
Use standardized terminologies
Interoperable systems are those that can share data in an understandable way with other systems. To do this each system must format data entered in the system in the same way. To achieve data exchange between interoperable systems requires that data be formatted in a standard manner.
Standardized healthcare terminologies allow for the design of interoperable information systems. Standardized terminologies, also called ontologies or healthcare system languages, have been designed to describe patient diagnoses, interventions, and outcomes.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

4. Health IT Workforce Curriculum Version 1.0/Fall 2010
Terminology
Special technical language used in a particular field of interest also called language for special purposes (LSP)
Set of terms representing the system of concepts of a particular subject field (ISO)
Terminologies are special languages that are developed to allow members of a certain area of expertise to communicate about a particular domain. Terminologies describe concepts within an area of knowledge with terms and definitions that all within the knowledge community agree upon and understand.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

5. Standardized Terminologies
Allow the tracking of adverse events
Documentation of services for reimbursement
Advance the science of care delivery
Allow the comparison of data captured in different systems for outcome management
Facilitates the linkage of diagnosis-interventions-outcomes
Standardized terminologies in healthcare standardize the collection of patient data so that data can be extracted in such a way that they can be analyzed to determine the safety, effectiveness, and outcomes of clinical practice.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

6. Health IT Workforce Curriculum Version 1.0/Fall 2010
Classifications
Taxonomic structures most commonly used in health care are classification systems
Non-combinatorial hierarchical languages designed to categorize objects
Objects classified are generally patient diagnosis and care interventions and implemented as interface terminologies at the point of care (i.e. ICD-9)
Classifications are the most common type of standardized language used in healthcare. Classifications are hierarchical, that is they arrange terms and definitions in the language with less specific categories listed at the highest level and more specific instances of these categories organized under them. In healthcare, classifications are used to describe patient diagnoses, interventions of care, and patient outcomes.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

7. Common Medical Terminologies
Current Procedural Terminology (CPT)
Diagnosis Related Group (DRG)
International Classification of Diseases (ICD)
International Classification
of Diseases-10-Clinical
Modification (ICD-10-CM)
Examples of terminologies commonly used in medicine include the current procedural terminology that is used to code medical procedures for documentation and billing purposes, the Diagnosis Related Group codes that are used to classify hospital diagnoses into approximately 750 groups, and perhaps the oldest example of a healthcare classification, the International Classification of Diseases. The 10th version of the International Classification of Diseases was published by the World Health Organization (WHO) in The WHO permitted an adaptation for use in the United States and the ICD-10-Clinical Modification is planned for implementation on October 1, 2013.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

8. Common Nursing Terminologies
North American Nursing Diagnosis Assoc ion (NANDA)
Clinical Care Classification (CCC)
Nursing Intervention Classification (NIC)
Perioperative Nursing Data Set (PNDS)
International Classification for Nursing Practice (ICNP®)
Terminologies commonly used to describe nursing practice, include, but are not limited to the North American Nursing Diagnosis Association classification of nursing diagnoses; the Clinical Care Classification and Nursing Intervention classifications used to describe nursing practice in both home and acute care; the Perioperative Nursing Data Set used to describe operating room nursing practice; and the International Classification for Nursing Practice increasingly being used internationally to describe nursing diagnoses, interventions, and outcomes.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

9. National Committee on Vital and Health Statistics
Recommends adoption of Health Level-7 for messaging, clinical encounters
Recommends adoption of 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 the terminologies Health Level-7 and SNOMED CT into all healthcare information systems.
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Health IT Workforce Curriculum Version 1.0/Fall 2010

10. Health IT Workforce Curriculum Version 1.0/Fall 2010
SNOMED CT
Systemized Nomenclature Medicine-Clinical Terms
An agreement has been signed between the US Government and College of American Pathologists allowing free distribution of SNOMED CT in the US
SNOMED CT (pronounced snow-med-C-T) is the Systemized Nomenclature (pronounced know-men-clay-ture) of Medicine and Clinical Terms. This language is really a compilation of many of the healthcare terminologies organized together in one terminology structure, including commonly used medicine and nursing languages.
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Health IT Workforce Curriculum Version 1.0/Fall 2010

11. Health IT Workforce Curriculum Version 1.0/Fall 2010
Health Level 7
Level Seven refers to the highest level of the International Organization for Standardization (ISO)terminology model for exchange of information between information systems
Addresses definition of the data to be exchanged, the timing of the interchange, and the communication of certain errors to the application
HL7 (pronounced H L Seven) is a language model that can be used to transform data from one system into a format that can be read and understood by another information system.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

12. Logical Observation Identifier Name Codes
Originally developed to provide a standard set of codes and names for the electronic reporting of laboratory results
LOINC has expanded to include items related to the measurement of clinical observations, such as blood pressure and symptoms
The preferred standardized terminology for representing laboratory data in information systems is the Logical Observation Identifier Names Codes or LOINC. LOINC not only provides a standard manner for representing laboratory data, but can also be used to represent physiological patient data in a standardized manner.
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010

13. Health IT Workforce Curriculum Version 1.0/Fall 2010
Summary
To achieve data exchange between interoperable systems requires that data be formatted in a standard manner
Standardized healthcare terminologies allow for the design of interoperable information systems
Standardized healthcare terminologies describe patient diagnoses, interventions, and outcomes
In summary, to achieve data exchange between interoperable systems requires that data be formatted in a standard manner;
Standardized healthcare terminologies allow for the design of interoperable information systems; and
Standardized healthcare terminologies describe patient diagnoses, interventions, and outcomes
Component 3/Unit 17a
Health IT Workforce Curriculum Version 1.0/Fall 2010