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4 Health Care Data Standards
Pages 127-168

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From page 127...
... Common data standards also support effective assimilation of new knowledge into decision support tools, such as an alert of a new drug contraindi cation, and refinements to the care process. This chapter provides both a short overview introducing data standards to the lay reader and a more technical review of the specific data standards required for the informatics-oriented professional.
From page 128...
... What Are Data Standards? In the context of health care, the term data standards encompasses methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of information associated with health care applications, including medical records, medications, radiological images, payment and reimbursement, medical devices and monitoring systems, and administrative processes (Washington Publishing Company, 1998)
From page 129...
... At the most basic level, data standards are about the standardization of data elements: (1) defining what to collect, (2)
From page 130...
... 130 PATIENT SAFETY TABLE 4-1 Comprehensive List of Health Care Data Sources and Reporting Requirements Clinical Datasets Other Data Sources for Patient Safety Information Histories Policies and procedures Allergies Human resources records Immunizations Materials management systems Social histories Time and attendance records Vital signs Census records Physical examination Decision support alert logs • Physicians' notes Coroners' datasets • Nurses' notes Claims attachments Laboratory tests Admissions data Diagnostic tests Disease registries Radiology tests Discharge data Diagnoses Malpractice data Medications Patient complaints and reports of adverse Procedures events Clinical documentation Reports to professional boards Clinical measures for specific clinical Trigger datasets (e.g., antidote drugs for conditions adverse drug events) Patient instructions Computerized physician order entry Dispositions systems Health maintenance schedules Bar-code medication administration systems Clinical trial data
From page 131...
... Private sector -- subsets • National Center for Health Statistics • Medical Event Reporting System for (NCHS) Transfusion Medicine (MERS TM)
From page 132...
... Data Interchange Standards In the area of data interchange, standards are needed for message format, document architecture, clinical templates, user interface, and patient data linkage. Message Format Standards Message format standards facilitate interoperability through the use of common encoding specifications, information models for defining relationships between data elements, document architectures, and clinical templates for structuring data as they are exchanged.
From page 133...
... . The HL7 V2.x series is the primary data interchange standard for clinical messaging and is presently adopted in 90 percent of large hospitals (American National Standards Institute, 2002)
From page 134...
... . HL7 V3 and the RIM are particularly important to the advancement of integrated clinical systems because they provide the backbone for the next set of standards needed for the EHR including those required for the use of concept-oriented terminologies, document architectures, clinical templates, alerts and reminders, and automated clinical guidelines, all of which would result in improved interoperability and structuring of clinical and patient data.
From page 135...
... Relationship Act Link Relationship Entity Role Participation Act Patient Referral Organization Employee Transportation Living subject Practitioner Supply Material Assigned Procedure Place practitioner Condition node Health chart Specimen Consent Observation Medication Act complex Financial act FIGURE 4-1 HL7 reference information model. SOURCE: Hammond, 2002.
From page 136...
... For greater precision in standardization of clinical data, more targeted specifications of the allowable values for the data elements must be applied.
From page 137...
... Consideration of the HE74 standard may provide insight into the processes employed for designing and developing user-friendly clinical information systems, including electronic patient safety reporting systems. An overview of the human factors engineering process that governs HE74 is provided in Figure 4-2.
From page 138...
... . The last step -- implementation and deployment -- is related to the manufacturing, marketing, sales, and regulatory aspects of the device/system, including postmarket surveillance and vigilance reporting that provide critical data on design strengths and shortcomings (Association for the Advancement of Medical Instrumentation, 2001)
From page 139...
... The context manager standard establishes the primary architecture, a core set of data definitions, rules for application user interfaces, security specifications, and translation of the architecture for interoperability with applications in a way that is technology neutral (Van Hentenryck, 2001)
From page 140...
... Context manager tells patient Application do so by the CM. Each mapping agent that context Patient ZZ application gets the new change is occurring; mapping Mapping Demographics patient context from CM.
From page 141...
... Patient Data Linkage While not a data standard in the traditional sense, being able to link a patient's health care data from one departmental location or site to another unambiguously is important for maintaining the integrity of patient data and delivering safe care. The administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA)
From page 142...
... ; and data reuse for multiple purposes, such as automated surveillance, clinical decision support, and quality and cost monitoring. To promote patient safety and enable quality management, standardized terminologies that represent the focus (e.g., medical diagnosis, nursing diagnosis, patient problem)
From page 143...
... While a number of diverse terminologies are required for clinical care, patient safety, and other aspects of biomedicine, a central group of terminologies can serve as the backbone of clinical information systems. A number of technical criteria must be met for terminologies to function in a way
From page 144...
... . The National Committee on Vital and Health Statistics (NCVHS)
From page 145...
... . Desired Technical Criteria Meaningless identifiers Unique codes attached to concepts are not tied to hierarchal position or other contexts and do not carry any meaning (Chute et al., 1998)
From page 146...
... Evolution and Development of New Terms In cases where domain coverage of a terminology is inadequate, the best sources of data for the development of new terms to represent clinical and patient safety information are the clinical measures within standardized datasets for a health condition derived from evidence-based guidelines, documentation of physical findings, and narrative text of patient safety reports. Once comprehensive datasets have been identified, it may be possible to develop extensions of existing terminologies for those areas that are insufficient in representing clinical or safety data.
From page 147...
... Nursing, including: Units (UMLS) Diagnoses Interventions Goals and outcomes Physiology Supplies, including Ontology for the ordering physician Medical devices adverse events, and medical errors for both commission and omission, as the basis for expanded clinical documentation in integrated systems.
From page 148...
... Terminologies to be included in the core group must have sufficient clinical granularity and serve multiple functions, including decision support, interoperability, aggregation and reporting, EHR data entry, order entry, indexing for data retrieval, and domain ontology. Supplemental terminologies should be mapped to the core terminologies to provide the functionalities associated with the use of data standards and information systems.
From page 149...
... LOINC has already been designated by CHI (in May 2003) as the terminology for representing laboratory test results and is a part of the NCVHS core terminology group (Consolidated Health Informatics Initiative, 2003)
From page 150...
... Universal Medical Device Nomenclature System (UMDNS) -- developed by the Emergency Care Research Institute as a multihierarchical terminology for identifying, processing, filing, storing, retrieving, transferring, and communicating data about medical devices.
From page 151...
... Current Dental Terminology -- developed by the American Dental Association to represent data related to dentistry. Terminologies for Further Research International Classification of Primary Care (ICPC)
From page 152...
... . For purposes of standardizing data elements for patient medical records information, the core terminology group will be focused on definitional terms.
From page 153...
... Medical device terminologies A medical device terminology is also a must for the core terminology group. The two medical device terminologies being considered by NCVHS are the Global Medical Device Nomenclature (GMDN)
From page 154...
... To satisfy the needs for the NHII and the EHR, computer-executable aggregation logic would stem from SNOMED CT and the other terminologies in the core group to the supplemental terminologies. It is also critical that the integration and mapping of the terminologies be based on the same information model as that of the data interchange standards -- the HL7 RIM -- to ensure optimum system functionality and interoperability (National Committee on Vital and Health Statistics, 2003a)
From page 155...
... , and the use of computer-readable evidence-based clinical guidelines. The supplemental terminologies outlined in Box 4-1 would be mapped through aggregation logic to the NCVHS core terminology group.
From page 156...
... . Preliminary findings suggest that in their current state, ICF terms lack unambiguous clarity, fidelity, and hence usability across the ranges of clinical data and granularity required for the varied and extensive use cases that rely on the representation of functional status data (Ruggieri et al., forthcoming)
From page 157...
... A conceptual diagram of the core terminology group and associated mappings to supplemental terminologies is presented in Figure 4-4, which shows the possible relationships among the terminologies and the use of aggregation logic for mapping through various levels of granularity. This figure was developed as a modification of a presentation in August 2002 to Administrative Code Sets Information Model Clinical Code Sets Mapping and Interface Aggregation Logic ICD Terminologies Nursing Terms CDT Core Terminology Group SNOMED CT Laboratory LOINC RxNORM UMDNS Clinical Drug Knowledge Specialty Bases Code Sets CPT Messaging and Public Health Code Sets HCPCS FIGURE 4-4 Conceptual diagram of the core terminology group and mappings to supplemental terminologies.
From page 158...
... With the development and use of common data standards, this linkage for enhanced access to medical knowledge bases can occur. Clinical Guideline Representation Model An earlier IOM report defines practice guidelines as systematically developed statements to assist practitioners and patients in making decisions about health care for specific circumstances (Institute of Medicine, 1992)
From page 159...
... facilitate standard approaches to guideline dissemination and local adaptation, and (4) be used as a template for the integration of automated clinical guidelines with clinical information systems (Wang et al., 2002b)
From page 160...
... . These requirements will differ from one clinical information system to another based on functionality supported by the system (e.g., whether computerized physician order entry is present, or whether automatic alerts or time-driven scheduling reminders are supported)
From page 161...
... . Such application interface tools would greatly enhance the usability of medical knowledge bases and capabilities for information seeking at the point of care (Humphreys, 2003a)
From page 162...
... . Common data standards can facilitate interconnections with bar-code medication administration systems, computerized physician order entry systems, and other decision support tools for the clinician and can support the self-care of patients by providing access to drug interaction checking programs.
From page 163...
... The entity might assist organizations in increasing staff awareness and education; undertaking a gap analysis of current and desired standards; formulating a strategic plan, budget, and timeline to meet the CHI requirements; implementing the plan and certifying conformance; and providing an audit process for ongoing monitoring and enforcement. In contrast with HIPAA, however, self-certification should not be an option for compliance with clinical data standards.
From page 164...
... NLM would have responsibility for estimating the costs related to the development and maintenance of the core terminology group and mappings to supplemental terminologies. Together, these organizations should engage in a comprehensive evaluation of the costs to provide the data standards needed for the NHII and patient safety systems.
From page 165...
... Personal communication to Institute of Medicine's Committee on Data Standards for Patient Safety.
From page 166...
... 2002. Overview of Health Care Data Standards.
From page 167...
... Personal communication to Institute of Medicine's Committee on Data Standards for Patient Safety. Seliger, R., and B
From page 168...
... 2001. ICF Introduction: International Classification of Functioning, Disability and Health.


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