HM311

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Introduction to Information Systems
for Health Information Technology
Chapter 12: Standards
© 2020 American Health Information Management
Association

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Learning Objectives, 1
Explain the necessity for standards in health information technology
(H I T)
Explain how Health Level Seven International (HL7) influences
healthcare data standards
Clarify the difference between the continuity of care record and the
continuity of care document
Compare and contrast data content standards, vocabulary
standards, and messaging standards

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Learning Objectives, 2
Describe how Systematized Nomenclature of Medicine Clinical
Terms (S N O M E D C T) works to achieve uniform terminology
Identify the need for mapping
Differentiate among national drug codes (NDC), RxNorm, and
National Council for Prescription Drug Programs (NCPDP)

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Standards, 1
A scientifically based statement of expected behavior against which
structures, processes, and outcomes can be measured
Should be technology-neutral and not rely on any one type of
technology to work
Must also be neutral to implementation processes, which vary
widely, and not prefer one vendor over others

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Standards, 2
Public-private partnerships are one way governance issues can be
addressed and resolved
Public-private partnership: A contractual arrangement between a
public agency (federal/state/local) and a private sector entity
• Through agreement, skills and assets of each sector (public and private) are
shared in delivering a service or facility for use of the general public.
• Each party shares the risk and reward potential in the delivery of the service
and/or facility

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Standards, 3
Standards development organizations (SDOs): Private or
government organizations that create or approve standards at the
national or international level.

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Standards Development Organizations, 1
There are many SDOs for H I T and H I Es
However, standards developed by different Health I T and H I E
organizations may overlap or compete with each other
Standards allow smooth exchange and incorporate data from all
sites, vendors, and specialties across the healthcare continuum
Unfortunately, sometimes that leaves HCOs struggling with
interoperability issues

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Standards Development Organizations, 2
International Standards Organization (I S O): A large, widely-
recognized international SDO that has established many standards
for E H R architecture and content
Has established many standards for E H R architecture and content
More than 22,000 standards for technology and manufacturing
Takes approximately three years for the I S O to review and approve
a standard

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Standards Development Organizations, 3
General areas of standards for H I T:
• Vocabulary/terminology: A specific set of values for a specific data type
• Transport messaging: How information is sent and exchanged between
systems
• Security: Provides assurances that messages are protected
• Content: Identifies what data elements are included, where they are located,
data type, field length, and so on
• Technical: Usually a formal document that established uniform engineering or
technical criteria, methods, processes, and practices

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Standards Development Organizations, 4
American National Standards Institute (A N S I) is the SDO for
the United States and a representative to the I S O
• Does not develop standards but provides neutral environment for
organizations and entities to work together to settle on common agreement for
standards the format, content, requirements, etc.

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Standards Development Organizations, 5
Before standard can be approved, must meet the rules of A N S I
and the following requirements:
• Made from consensus: How agreements are determined
• Due process: Procedures and specific committees that perform the critique,
review the proposed standard, and eventually approve the proposed standard
• Openness: Transparency of all procedures to all parties
• Balance: A platform for standards development that withstands scrutiny while
protecting the rights and interests of all members

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Standards Development Organizations, 6
I S O developed a six-step process for organizations that request
approval for specified standards:
• Proposal: Stakeholders agree there is a need for a particular standard
• Preparatory: Draft of proposed standard is submitted
• Committee: Draft is analyzed and revised by committee until consensus is
reached
• Enquiry: Proposed standard is available for review and comment by all
stakeholders
• Approval: Final draft is voted upon for approval
• Publication: Standard is published

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Standards Development Organizations, 7
ASTM International is well known in other areas of industry, but its
healthcare aspect is only in the United States
United States division—Committee E31 addresses standards for:
• Healthcare data management,
• Privacy, confidentiality and security,
• As well as data analyses and information capture and documentation
• To help practitioners preserve and transfer accurate patient information using
E H R technologies

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Data Content Standards, 1
Clear guidelines for the acceptable values for specified data fields
Make it possible to exchange health information using electronic
networks
Identify the structure and content of data elements to be collected by
the E H R

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Data Content Standards, 2
Allow organizations to collect data once and use it many times in
many ways
Assist in data storage and mining as well as sharing data with
external organizations for use in benchmarking and other purposes
Assists in the H I E process

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Data Content Standards, 3
Health Level Seven International (HL7)
• Founded in 1987 as a not-for-profit A N S I-accredited SDO
• Dedicated to providing a comprehensive framework and related standards of
electronic health information that supports clinical practice and management,
delivery, and evaluation of health services for:
• Exchange
• Integration
• Sharing
• Retrieval

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Data Content Standards, 4
HL7 developed standards for electronic exchange of clinical
documents (discharge summaries, progress notes, etc.) referred to
as clinical document architecture (CDA)
• CDA uses HL7XML-based document markup standards for the electronic
exchange model for the creation of clinical documents such as discharge
summaries and progress notes

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Data Content Standards, 5
Implementation guides are included with each standard and define
how to use specific standard for specific purposes
Implementation guide removes optionality
• It states what data elements are required and when so there is no room for
interpretation

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Continuity of Care Record (CCR)
ASTM International created the CCR
Identifies core data set of patient information that must be passed on
to next healthcare provider to efficiently and effectively continue the
patient’s healthcare
CCR was designed for all patient referrals and transfers

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Standards Development Organizations, 8
Core data set for the CCR contains:
• Document identifying information
• Patient identifying information
• Insurance and financial information of the patient
• Patient’s health status
• Care documentation and plan recommendations
• Advanced directives
• List of healthcare providers involved in care of patient

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Standards Development Organizations, 9
Continuity of Care Document (CCD): An implementation guide for
sharing CCR patient summary data
• Result of joint effort between ASTM International and HL7
• Fosters interoperability of clinical data
• Allows physicians to send electronic medical information to other providers without loss of
meaning
• Enables improvement of patient care using the HL7 Version 3 Clinical Document
Architecture (CDA), Release 2

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Vocabulary Standards, 1
List or collection of clinical words or phrases with their meanings
• Addresses the problem of multiple ways to define, classify, and represent
language
Medicine has its own language
Many terms used in medicine that have multiple synonyms
• “Medical,” “therapeutic,” and “curative”
• “Drug,” “medication,” and “pharmaceutical”

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Vocabulary Standards, 2
Language: System of communication used by a group of people
Vocabulary: All terms that are used for communication within area
of specialization
Terminology: The words used for a specific purpose
Nomenclature: A system used to assign names

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Vocabulary Standards, 3
Each term included in the vocabulary should have a unique meaning
Terminologies and vocabularies can have overlapping terms due to
synonyms and eponyms
One of the challenging aspects of medicine and application of E H R
and diagnostic software to interpret unstructured (and sometimes
structured) text from healthcare provider

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Systematized Nomenclature of Medicine Clinical Terms (S N O M E
D C T), 1
Most comprehensive, multilingual clinical healthcare terminology in
the world
Contributes to the improvement of patient care by underpinning the
development of E H Rs that record clinical information in ways that
enable meaning-based retrieval

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Systematized Nomenclature of Medicine Clinical Terms (S N O M E
D C T), 2
The S N O M E D C T concepts table consists of more than
• 344,000 concepts
• 450,000 medical descriptions
• 700,000 concept interrelations

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Logical Observation Identifiers Names and Codes (L O I N
C)
Preferred standardized terminology for laboratory data in I S
• Provides standard set of codes and names for electronic reporting of
laboratory results
Expanded to include observational data such as vital signs
Used for standardized assessments and care plans in long-term
care and home health

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RxNorm
Clinical drug nomenclature developed by the Food and Drug
Administration, the Department of Veterans Affairs, and HL7 to
provide standard names for clinical drugs and administered dose
forms
Nonproprietary
Provides standards for drug ingredients and strength, dose formats,
drug properties, physiological effects, and therapeutic category

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Unified Medical Language System (U M L S), 1
Developed by the National Library of Medicine (NLM)
Designed to build an automated system that can understand
biomedical concepts, words, and expressions and their
interrelationships
Includes concepts and terms from many different vocabularies

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Unified Medical Language System (U M L S), 2
Two key concepts of U M L S:
• Semantics: Branch of linguistics dealing with the study of meaning, including
the ways meaning is structured in language and how changes in meanings
and form occur over time
• Syntax: The study of patterns of formation of sentences and phrases from
words and the rules for the formation of grammatical sentences in a language

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National Drug Codes (NDC)
Developed by the Food and Drug Administration to act as universal
unique identifier for human drugs
NDC identifies the labeler or vendor, product, and trade package
size

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Current Dental Terminology (CDT)
Used to code dental procedures such as tooth extractions, tooth
implants, etc.
Developed by the American Dental Association
Includes diagnostic, preventive, restorative, endodontics,
periodontics, and other dental procedures

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MEDCIN, 1
Nomenclature and knowledge-based system
Controlled by Medicomp Systems, Inc.

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MEDCIN, 2
Most comprehensive vocabulary for signs and symptoms
Includes 250,000 clinical data elements:
• Symptoms
• Health history
• Physical examination
• Tests
• Diagnoses
• Therapy

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Diagnostic and Statistical Manual of Mental Disorders
(DSM), 1
Classification system of mental disorders used by mental health
providers
Assist physicians in properly diagnosing patients with mental health
conditions
Published by the American Psychiatric Association
Current edition is DSM-5

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Diagnostic and Statistical Manual of Mental Disorders
(DSM), 2
New format of ICD-10-CM codes was applied to DSM-5
DSM-5 provides detailed and specific criteria and information for
physicians to accurately diagnose the mental disorder(s) of the
patient

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Mapping, 1
A crosswalk between the various terminologies must be created
Allows for interoperability
Process of associating concepts from one coding system with
concepts from another coding system and defining their equivalence
in accordance with a documented rationale and a given purpose

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Mapping, 2
One-to-one: An exact match is made between the systems
Narrow-to-broad: A more granular term in the starting system maps
to a more general term in the receiving system
Broad-to-narrow: A more general term in the starting system maps
to a more granular term in the receiving system

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Mapping, 3
Unmappable: There is no matching into the receiving system
General Equivalence Mappings (G E Ms)
• Created by the Centers for Medicare and Medicaid Services (CMS)
• G E Ms are used to convert ICD-9-CM codes to ICD-10-CM/PCS codes or the
reverse

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Messaging Standards, 1
May also be called interoperability standards or data exchange
standards
Support communications between information systems
Proprietary systems are able to talk to one another, allowing the
exchange of data

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Messaging Standards, 2
Standards do this by mapping proprietary forms to other formats
Existing standards have allowed for flexibility, which has caused
problems with the interoperability between systems

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Electronic Data Interchange (E D I)
A N S I Accredited Standards Committee (ASC) X12 Insurance
Subcommittee develops messaging standards for electronic data
interchange (E D I)
E D I is the exchange of routine business transactions from one
computer or information system to another in a standard format,
using standard communications protocols

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Messaging Standards, 3
ASTM International develops standards for security, health record
content, the continuity care record, and the exchange of laboratory
data
Examples of messaging standards include:
• Health Level 7 (HL7)
• Digital Imaging and Communications in Medicine (D I C O M)
• National Council for Prescription Drug Programs (NCPDP)

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Messaging Standards, 4
Digital Imaging and Communications in Medicine (D I C O M)
• Standard retrieves images and other information from imaging equipment from
many vendors
• Covers message exchange, data dictionary, data structure, encoding, etc.
• Started out in diagnostic medical imaging
• Has broadened to include specialties cardiology, dentistry, and radiology

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Messaging Standards, 5
A N S I Accredited Standards Committee X12N (ASCX12N)
• Responsible for developing E D I standards used to share information needed
for health insurance administrative transactions
• Includes functions such as benefit enrollment and maintenance and
healthcare claim payment and advice

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Messaging Standards, 6
National Council for Prescription Drug Programs (NCPDP)
Independent SDO
A N S I-accredited

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Messaging Standards, 7
Developed for and used by retail pharmacies and payers for claims,
eligibility, and remittance advice
These e-prescription standards, called SCRIPT, control data to be
shared for new prescriptions, refills, and other communications
between physicians and pharmacies