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HEALTHCARE DATA STANDARDS
Transcript of HEALTHCARE DATA STANDARDS
HEALTHCARE DATA STANDARDS & ELECTRONIC HEALTH RECORDS SYSTEMS
ELECTRONIC HEALTH RECORDS SYSTEMS
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 enables:
Data collection at the point of care
Retrieval of data/information
Knowledge in support of clinical practice
International Statistical Classification of Diseases and Related Health Problems: 9th Revision and Clinical Modifications
It is the latest version of a mortality and morbidity classification that originated in 1893.
It is widely accepted, used in the healthcare industry and has been adopted for a number or purposes:
Quality of care analysis
It is the basis for diagnostic related group which are use extensively for hospital reimbursement.
It is internationally used for death tabulation.
International Statistical Classification of Diseases and Related Health Problems: 10th Revision and Clinical Modifications
It is the most recent revision of the ICD classification system for mortality which is used worldwide.
Current ProceduraL Terminology:
(CPT – 4 )
It is a listing of descriptive terms and codes for reporting medical services and procedures.
In addition to descriptive terms, it contains:
Notes and Guidelines to facilitate correct usage
SYSTEMATIZED NOMENCLATURE OF HUMAN VETERINARY MEDICINE INTERNATIONAL, CLINICAL TERMS (SNOMED)
Is a comprehensive multiracial nomenclature and classification system for indexing human and veterinary medical vocabulary.
It also includes:
Signs and Symptoms
LOGICAL OBSERVATION IDENTIFIERS NAME AND CODES (LOINC)
It provide a set of universal names and numeric identifier codes for laboratory and clinical observations and measurements in a data base structure.
It represents laboratory data in terms of names for tests and clinical observations.
It is clear that such consistency in terminology is important for patient’s safety.
It is a clinical drug nomenclature produced by NLM in consultation with:
Food and Drug Administration (FDA)
Department of Veterans Affairs
It provide standard names for clinical drugs (active ingredients + strength + dose form) and for those forms as administered.
It provide links from clinical drugs to their active ingredients, drug component (active ingredient + strength) and some related brand names.