Chapter 5 Clinical Classification, Vocabularies, Terminologies, and Standards Flashcards
Basic Interoperability
Relates to the ability to successfully transmit and receive data from one computer to another
Clinical Care Classification (CCC)
Two interrelated taxonomies the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings
Clinical Classification
A clinical vocabulary, terminology, or nomenclature that list words or phrases with their meanings; provides for the proper use of clinical words as names or symbols; facilitates mapping of standardizes terms to broader classification for administrative, regulatory, oversight, and fiscal requirements Example: ICD-10-CM
Clinical Documentation Architecture (CDA)
An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule
Clinical Information Model (CIM)
Consisting of unambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions.
Clinical Terminology
A set of standardized term and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement. Example: SNOMED CT
Clinical Vocabulary
A formally recognized list of preferred medical terms
Concept
The most granular unit within a terminology defined as a signal clinical meaning identified by a unique numeric identifier.
Continuity of Care Document (CCD)
The result of ASTM’s Continuity of Care Record standard content being represented and mapped into the HL7’s Clinical Document Architecture specifications to enable transmissions of referral information between providers; also frequently adopted for personal health records
Continuity of Care Record (CCR)
Is a core data set of the most relevant administrative, demographic, and clinical information about a patient’s health care, covering one or more healthcare encounters. It provides a means for one health care practitioner, system, or setting to aggregate all of the pertinent data about a patient forward it to another practitioner, system, or setting to support the continued care
Current Dental Terminology (CDT)
A reference manual maintained and updated annually by the American Dental Association.
Current Procedural Terminology (CPT)
Provides a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5)
A handbook used by professionals as a guide to diagnose mental disorders and was first published by the American Psychiatric Association (APA).
Functional Interoperability
Sending messages between computers with a shared understanding of the structure and format of the message.
Healthcare Common Procedure Coding System (HCPCS)
Used to report services and supplies primarily for reimbursement purposes in the outpatient or ambulatory setting.
Interface Terminology
Terminology concerned with facilitating within the standardized structure needed for an electronic health record.
International Classification Disease (ICD)
Facilitates the storage and retrieval of diagnostic information and serves as the basis for compiling mortality and morbidity statistics reported by WHO members.
International Classification Disease, 10th Revision, Clinical Modification (ICD-10-CM)
For reporting of morbidity data and reimbursement in the United States.
International Classification Disease, 10th Revision, Procedure Coding System (ICD-10-PCS)
The coding classification system that replaced ICD-9CM, volume 3, on October 1, 2015. ICD-10-PCS has 16 sections and contains significantly more procedure codes than ICD-9-CM, providing the ability to code procedures with greater level specificity.
International Classification Disease, 11th Revision (ICD-11)
Designed to include linkages to standardized healthcare terminologies to facilitate processing and use of the data for a variety of purposes such as research
International Classification Disease for Oncology, 3rd edition (ICD-O-3)
A system used for classifying incidences of malignant disease
International Classification of Primary Care (ICPC-2)
Classification used for coding the reasons of encounter, diagnoses, and interventions in an episodeof-care structure
International Classification on Functional, Disability, and Health (ICF)
Classification of health and health-related domains that describe body functions and structures, activities, and participation
International Health Terminology Standards Development Organization (IHTSDO)
An international nonprofit organization based in Denmark that maintains and distributes the Systemized Nomenclature of Medicare-Clinical Terminology
Interoperability
The ability to exchange information between computer systems
Lexicon
The listings of words or expressions in a language (terminology) and information about the language such as definitions, related principles, and description of (grammatical) structure.
Logical Observation Identifiers Names and Codes (LOINC)
A database protocol developed by the Regenstrief Institute of Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research that enables exchange and aggregation of electronic health data for many independent systems
Mapping
A function that allows for the reuse of data captured for one purpose to be used for other purposes.
MEDICIN
A proprietary clinical terminology owned and maintained by Medicomp Systems.
Medical Subject Headings Database (MeSH)
The NLM’s controlled vocabulary thesaurus consisting of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity.
Morphology
Describes the characteristics of the tumor itself, including cell type and biologic activity.
Multiaxial
(five axes) The coding system for the documentation of diagnosis
National Drug Codes directory (NDC)
Developed by the FDA to serve as a universal product identifier for human drugs.
National Library of Medicine (NLM)
To facilitate the development of computer systems that behave as if they “understand” the meaning of the language of biomedicine and health. The ULMS provides data for system developers as wells as search and report functions for less technical users.
Nomenclature
A recognized system of terms used in a science or and art that follows preestablished naming conventions Example: HL7
Patient Medical Record Information (PMRI)
Information in which SNOMED CT is a part of a core set of terminology
Reference terminology
A set of concepts and relationships that provides a common reference point for comparison and aggregation of data about the entire healthcare process, recorded by multiple different individuals systems, or institutions.
Relationship
Describe how the concepts within SNOMED CT are linked to another.
RxNorm
A standardized nomenclature for clinical drugs that provides information on a drug’s ingredients, strengths, and form in which it is to be administered or used.
Semantic Interoperability
Similar to HL7 in that the information being transmitted is understood
Systemized Nomenclature of Medicine-Clinical Terminology (SNOMED CT)
The most comprehensive, multilingual clinical healthcare terminology in the world. SNOMED CT contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways that enable meaning-based retrieval
Systemized Nomenclature of Medicine-Reference Terminology (SNOMED RT)
In 1997, the College of American pathologist worked with a team of physicians and nurses from the Kaiser Permanente to begin development of SNOMED RT, which came to be recognized as a reference terminology by the inclusion of an elementary mapping to ICD-9-CM
Terminology
A set of terms representing a system of concepts.
Topography
The south of origin of the neoplasm and uses the same three-and four-character categories as in the neoplasm section of second chapter of ICD-10.
Transition of Care initiative (ToC)
The exchange of clinical summaries is hampered by ambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions.
Unified Medical Language System (UMLS)
A program initiated by the National Library of medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions in their interrelationships; includes concepts in terms from many different source vocabularies
