Data Standards Flashcards
data that are used to describe other data.
Meta Data
often accessed by search engines to determine which files to access.
Meta Data
define the electronic health record (EHR)as a “secure, real-time, point-of-care, patient-centric information resource for clinicians.”
Healthcare information and management systems society
have been developed to allow exchange of health information among different health care providers in a specified area, region, or system.
Health information exchanges (HIEs)
are developed to improve the delivery of health care. RHIPs cover all aspects of health care, including risk factors, diagnosis, treatment, disability, and social/mental factors, as well as all delivery systems, including hospitals, clinics, and individual practitioners.
Regional Health improvement plans (RHIPs)
three classification systems used in nursing informatics
NANDA-I
Nursing Interventions Classification (NIC)
Nursing Outcomes Classification (NOC)
provides uniform terms for patient problems that may occur during an operation.
The perioperative nursing data set (PNDS)
Includes diagnostic and intervention components.
The perioperative nursing data set (PNDS)
Provides documentation standards framework.
The perioperative nursing data set (PNDS)
comprehensive collection of clinical terms.
SNOMED CT
data dictionary designed to provide a standard set of terms (capturing clinical data) for inclusion in healthcare information systems.
Patient Care Data Set (PCDS)
This system was formerly known as Home Health Care Classification (HHCC)
Clinical Care Classification (CCC)
The system uses two major subsets of information:
Clinical Care Classification (CCC)
The terms used in the specific diagnosis and outcomes of a disease state.
Diagnoses and outcomes
For a given disease state, the appropriate interventions and actions.
Interventions and actions
There are 21 “Care Components” which classify care over a wide range of factors such as functional, physiological, and psychological.
Clinical Care Classification (CCC)
Uses a Problem Classification Scheme (assessment). This scheme allows for evaluating the condition of the patient.
Omaha System
prescribes the appropriate interventions to treat the problem (or disease state).
The Intervention Scheme
This database of terms is used primarily for laboratory results
Logical Observation Identifiers Names and Codes (LOINC)
provides uniform terms for nursing data.
International Classification for Nursing Practice (ICNP)
the goal is to create a system in which data can be examined and transmitted to other computers systems in a recognizable way.
International Classification for Nursing Practice (ICNP)
Categories for diagnosis, interventions, and outcomes.
International Classification for Nursing Practice (ICNP)
a dynamic collection of standardized terms related to nursing.
Nursing Management Minimum Data Set (NMMDS)
The goal is to create terms that will allow data to be compared across a wide swath of computer systems.
Nursing Management Minimum Data Set (NMMDS)
were developed by the American Medical Association and used to define those licensed to provide services as well as medical and surgical treatments, diagnostics, and procedures.
Current procedural terminology (CPT) codes
usually updated each October with revisions (additions, deletions) to coding.
CPT codes
mandated by both the Centers for Medicaid and Medicare and the Health Insurance Portability and Accountability Act (HIPAA) to provide a uniform language and to aid research.
CPT codes use
These codes are used primarily for billing purposes for insurance (public and private).
CPT codes
codes are used to identify a procedure or service.
Category I
codes are used to identify performance measures, including diagnostic procedures.
Category II
codes identify temporary codes for technology and data collection.
Category III
developed by the World Health Organization to acquire worldwide morbidity and mortality data, are used to code for diagnoses.
The International Classification of Disease (ICD) codes
diagnoses were used by all providers, but were used only for inpatients;
ICD-9 codes
is an HL7 workgroup that develops standard protocols for the sharing of information among applications at the point of care through context management.
Clinical Context Object Workgroup(CCOW)
defines the standards that allow interoperability and focuses on the use of technology neutral architecture and widely used computer technology.
CCOW
works in collaboration with the HL7 Security Workgroup to ensure protection of data.
CCOW
a nongovernmental organization, encompasses a network of standard institutes, public and private, in 164 countries and develops and publishes voluntary international standards based on consensus.
The International Organization for Standardization (ISO)
working toward implementing standards in the area of medical informatics.
The National Institutes of Health(NIH)
There are two major standards associated with nursing informatics
The Institute of Electrical and Electronic Engineers (IEEE) & The National Electrical Manufacturers Association
developed the P1073 Medical Information Bus (MIB) standards to aid in the transfer of information between patient medical devices and the hospital’s mainframe computer system.
The Institute of Electrical and Electronic Engineers (IEEE)
created Digital Imaging and Communications in Medicine (DICOM)
National Electrical Manufacturers Association and the American College of Radiologists
used in association with biomedical images and image-related information.
Digital Imaging and Communications in Medicine
One of the largest standards development organizations
the American Society for Testing and Materials (ASTM).
create standard methods for testing materials and procedural testing standards for different industries. F
role of the ASTM
an international standard developing organization that sets standards used in the sharing, retrieval, exchange, and integration of electronic health information (clinical and administrative) among different healthcare computer systems.
Health Level 7(HL7)
developed standards regarding functions needed in an EHR: direct care, supportive (administrative, financial), and information infrastructure (interoperability, security, workflow).
HL7
There are seven categories of standards for HL7:
primary, foundational, clinical and administrative domains, EHR profiles, implementation guides, rule and references, and education and awareness.
a standard for data formats and a web-based application programming interface (API) to facilitate the exchange of EHRs among healthcare providers.
fast healthcare interoperability resources (FHIR)
allows healthcare organizations to collect real-time data
fast healthcare interoperability resources (FHIR)
