Healthcare Data Standards and Exchange Flashcards
Four type of healthcare data standards created and maintained?
Ad hoc, De facto, mandate, consensus
Ad hoc standards:
developed as people and organization come together and agree to use a common but informally developed specification.
De facto standards:
emerge as one earns a large enough for a critical mass of adopters to make its system the standard.
Desirable factors for a standard:
cost, fitness for the intended purpose, ease of implementation.
HIT Standards Committee six criteria for standards:
Maturity of the specification, maturity of the underlying technology components, market adoption, ease of implementation and deployment, ease of operations, intellectual property.
Ontology definition:
formal representation of some pre-existing domain of reality in a way that allows it to support automatic information processing. In other words, a terminology that contains some formal representation of definitional information. Ontologies serve to represent a truth (ie., body temperature) and do not reflect the presence or absence of this knowledge.
ICD
International classification of diseases, used extensively as a billing mechanism in the US. Developed by the WHO.
CPT
Current procedural terminology, standardized terminology owned and maintained by the AMA, original focus was surgical procedures.
CPT Categories:
- Numeric codes for procedures that are within the scope of medical practice in the US, RVUs derived from this.
- Alphanumeric codes for tracking performance measurements, contain F designation, anticipated role in P4P.
- Temporary codes for new or emerging procedures, all contain the T designation.
Healthcare Common Procedure Coding System
billing coding system based on the AMA CPT, provides descriptive standard for billing services.
HCPCS categories:
- Numeric codes from AMA CPT.
2. Alphanumeric codes for primarily non-physician services that not represented in category 1.
DRG
Diagnosis-related group - a system that describes a bundle of services that a hospital might provide. Created to control costs.
SNOMED-CT
Multi-lingual clinical terminology that is used in many countries. First developed by the CAP. It is concept-oriented terminology that allows for machine readability.
LOINC
Logical observation identifies names and codes - universal coding system for identifying laboratory tests and clinical observations in electronic messaging. Widely adopted as the standards for laboratory and clinical observations.
RxNorm
standardized terminology set that provides normalized names for clinical drugs and links to synonyms.
NDF-RT
National drug file reference terminology is a standardized terminology system for modeling characteristics including ingredients, chemical structure, dose form, physiologic effect, mechanism of action, pharmacokinetics and related diseases. It is a part of RxNorm.
National Drug Code
Established by the Drug listing act of 1972, FDA all drugs must be registered.
CDT
Current dental terminology - HIPAA standards for dental procedures and for electronic dental claims.
UMLS
Unified medical language system - established to create a standard to link different standards.
CDA
Most widely recognized component of HL7 v3. Standards for specifying the structure and esamntics of clinical documents.
FHIR
fast healthcare interoperability resources - HL7 standards that looks to take the good portions of version 2 and 3 and merge them with a focus on implementation.
DICOM
Digital imaging and communications in medicine - international medical imaging standard for handling, storing, printing and transmitting across a specified network communications protocol with a specific format definition.
