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Standards in Medical Informatics

Standards in Medical Informatics. Standards Nomenclature Terminologies Vocabularies. What is a Standard?. A standard comprises a set of rules and definitions that specify how to carry out a process or produce a product ASCII EBCDIC

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Standards in Medical Informatics

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  1. Standards in Medical Informatics Standards Nomenclature Terminologies Vocabularies Fall 05

  2. What is a Standard? • A standard comprises a set of rules and definitions that specify how to carry out a process or produce a product • ASCII • EBCDIC • In medical informatics there is great emphasis on collection, manipulation, and transmission of information • Standards are greatly needed • Only recently wide availability Fall 05

  3. Standardized Identifiers • Individuals (patients) • Very controversial • Privacy issues • Healthcare providers • The Health Care Financing Administration has defined a National Provider Identifier • Health plans • Employers Fall 05

  4. Standards for Encoding Patient Data • Standards for encoding data about the patient that are collected by one system and used by another • The encoding of clinical knowledge using an accepted standard would allow many people and institutions to share the work done by others • The Arden Syntax is one such standard Fall 05

  5. Standards Development Process • Ad hoc method • American College of Radiology/National Electrical Manufacturers Association DICOM standard for medical imaging • De facto method • Single vendor monopoly (Microsoft Windows Operating System) Fall 05

  6. Standards Development Process… • Government mandate method • A government agency creates a standard and legislates its use • Consensus method • A group of volunteers representing interested parties work in an open process to create a standard • Most healthcare standards follow this method • Health Level Seven (HL7) standard for clinical data exchange Fall 05

  7. Stages of Standards Creation • Identification stage • A need for a standard is recognized • Conceptualization stage • Characteristics of the standard are defined • Discussion stage • Content definition • Timeline Fall 05

  8. Stages of Standards Creation… • Writing the draft standard • Implementation • Conformance • Compliance with the standard • Specific agreements among users of a standard • Certification • A neutral body certifies vendor products Fall 05

  9. Information Standards Organizations • American National Standards Institute (ANSI) • CEN Technical Committee 251 • The European committee for standardization • ISO Technical Committee 215 • American Society for Testing and Materials (ASTM) • ASTM committee E31 on computerized systems is responsible for the development of medical information standards Fall 05

  10. Information Standards Organizations… • Healthcare Informatics Standards Board • Healthcare models and Electronic Health Records • Exchange of clinical data, images, sounds etc. • Healthcare codes and terminology • Healthcare protocols and guidelines • Privacy, confidentiality and security • Computer Based Patient Record Institute (CPRI) Fall 05

  11. Health Insurance Portability and Accountability Act (HIPAA) • Signed into law in 1996 • Directive to Health and Human Services (HHS) to adopt standards • Health claims • Health plan enrollment • Healthcare payment • Health claim status • Coordination of benefits • Unique health ID for individual, employer, provider, health plan • Codes for transactions • Security standards Fall 05

  12. Terminology, Vocabulary and Nomenclature • Terminology • Set of terms representing the system of concepts of a particular subject field • Nomenclature • System of terms that is elaborated according to pre-established naming rules • Vocabulary • Dictionary containing the terminology of a subject field Fall 05

  13. Specific Terminologies • International Classification of Diseases and its Clinical Manifestations • ICD-9, ICD-9-CM • ICD-10 • 484 Pneumonia in infectious disease • 484.3 Pneumonia in Whooping Cough • 484.4 Pneumonia in Tularemia • 484.5 Pneumonia in Anthrax Fall 05

  14. Specific Terminologies… • Diagnosis Related Groups (DRG) • To provide a small number of codes for classifying patient hospitalizations • To provide some separation of cases based on severity of illness • Current Procedural Terminology (CPT) • Diagnostic and Statistical Manual of Mental Disorders (DSM) Fall 05

  15. Specific Terminologies… • Systematized Nomenclature of Medicine (SNOMED) • Read Clinical Codes • Developed by James Read in England • GALEN • National Drug Codes • Medical Subject Heading (MeSH) • Unified Medical Language System (UMLS) Fall 05

  16. Questions? Comments! Fall 05

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