HM480

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Health Information
Management: Concepts,
Principles, and Practice
Sixth Edition
Chapter 5
Clinical Classifications, Vocabularies,
Terminologies, and Standards

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Classification Systems, Vocabularies and
Terminologies
• Classification: A system for grouping similar
diseases and procedures and organizing related
information for easy retrieval
• Nomenclature: A system of terms structured
according to pre-established naming rules
• Clinical Terminology: A set of terms representing
the system of concepts in a particular field of study
or practice
• Clinical Vocabulary: A list or collection of clinical
words and phrases and their definitions

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Vocabularies and Terminologies
• Vocabularies are similar to terminologies with the
exception that vocabularies include the meanings
or definitions of words.

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Nomenclatures and Terminologies
• A nomenclature can be less specific than a
terminology, which is less specific than a language.
• While classifications and nomenclatures categorize
and aggregate, a terminology represents the whole
of a subject field.

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Classifications and Terminologies
• Clinical classifications and terminologies service
different functions:
• Classification systems represents similar procedures and
diagnoses with codes. This categorization of information
is useful for functions such as billing and monitoring
resource utilization.
• Terminologies exist to represent topics ranging from
nursing documentation and lab data to medical devices.
This detailed level of data capture is useful to support
functions such as clinical decision support and clinical
alerts.

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Classification Systems, Vocabularies and
Terminologies for Healthcare Data
• Each plays a specific yet interdependent role in data
standardization
• Data standardization exists to support different
healthcare functions
• Classifications are used to aggregate data for functions
such as data analysis and reimbursement
• Clinical terminologies play an essential role in capturing
and sharing data in a manner that meets the
requirements of interoperability

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Mapping
• Since no single system meets all needs, mapping is
a function that allows for the reuse of data
captured for one purpose to be used for other
purposes
• Mappings are sets of relationships of varying
complexity established between two vocabularies
in order to allow automated translation or
connection between them

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Mapping Use Cases
• Mapping requires a thorough understanding of the
intended use
• A map created for a reimbursement use case will very
different from that for a public health use case
• For this reason, the structure and purpose of the
source and target terminologies are also required

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Common Healthcare Classifications and
Code Sets
• International Classification of Diseases
• Maintained by the World Health Organization (WHO)
• Development of 11th edition (ICD-11) was recently
released (June 2018)
• ICD-11 includes linkages to standardized healthcare
terminologies
• Expected that transition from ICD-10 to ICD-11 will be
much more efficient than the transition of ICD-9 to ICD-
10

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International Classification of Diseases, Tenth
Revision
• ICD-10-CM (diagnosis coding) and ICD-10-PCS
(procedure coding) are the required CMS code set
in the US as of October 1, 2015
• ICD-10-CM is also used in the US for mortality
reporting
• General Equivalence Mapping (GEMs) were
developed to map relationships between ICD-9-CM
and ICD-10-CM/PCS codes for billing and reporting
purposes from 2016 through 2018

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ICD-10-CM/PCS
• The Centers for Medicare and Medicaid Services
(CMS) identifies ICD-10-CM as a system that
consists of more than 86,000 diagnosis and ICD-10-
PCS as consisting of 87,000 codes.
• Together, ICD-10-CM and ICD-10-PCS have the
potential to reveal more about quality of care so
that data can be used in a more meaningful to
better understand the health and care of patients.

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ICD-10-CM
• ICD-10-CM is a US clinical modification of the World
Health Organizations (WHO) ICD-10 and maintained
by the National Center for Health Statistics (NCHS).
• It is a morbidity classification that classifies diagnoses
and other reasons for healthcare encounters
• The code structure is alphanumeric, with codes
comprised of three to seven characters

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ICD-10-PCS
• ICD-10-PCS is a procedure coding system developed
under contract by the Centers for Medicare and
Medicaid Services (CMS)
• It is a replacement of the ICD-9-CM procedure coding
system for hospital reporting of inpatient procedures
• It has a seven-character alphanumeric code structure
• Each character can be one of 34 values

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Current Classifications and Nomenclatures
• International Classification of Diseases for
Oncology, 3rd Edition
• International Classification on Functioning,
Disability, and Health (ICF)
• Healthcare Common Procedure Coding System
(HCPCS)
• Current Procedural Terminology (CPT)
• Diagnostic and Statistical Manual of Mental
Diseases (DSM), 5th Edition

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Current Classifications and Nomenclatures
(continued)
• International Classification on Primary Care
• (ICPC-2)
• Current Dental Terminology (CDT)
• National Drug Codes (NDC)

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Other Healthcare Terminologies, Vocabularies,
and Classification Systems
• Healthcare terminologies facilitate exchange by
standardizing data collected
• The ability to share information between systems is
interoperability
• Functional interoperability
• Semantic interoperability
• Reference terminology:
• a set of concepts and relationships that provides a common
consultation point for comparison and aggregation of data about
the entire healthcare process, recorded by multiple different
individuals, systems, or institutions
• Interface terminology:
• is concerned with facilitating clinician documentation within the
standardized structure needed for an EHR.

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Other Healthcare Terminologies,
Vocabularies, and Classification Systems
• Systematized Nomenclature of Medicine, Clinical Modification
(SNOMED-CT)
• A comprehensive, multi-hierachical, concept-oriented clinical terminology
• Logical Observation Identifier Names and Codes (LOINC)
• Is the exchange standard for Lab LOINC and Clinical LOINC to identify
observations in HL7 messages as a universal standard for laboratory test names
• Clinical Care Classification (CCC) System
• Is two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes
and the CCC of Nursing Interventions and Actions to provide a standardized
framework for documenting patient care
• RxNorm
• A standardized nomenclature for clinical drugs
• MEDCIN
• Facilitates documentation by providing clinically relevant choices in a format
this is consistent with the providers thought processes.

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Emerging Healthcare Terminologies,
Vocabularies, and Classifications
• National Cancer Institute (NCI) Thesaurus
• Human Genome Nomenclature (HUGN)
• Global Medical Device Nomenclature (GMDN)
• Universal Medical Device Nomenclature System
(UMDNS)

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Emerging Healthcare Terminologies, Vocabularies,
and Classifications (Continued)
• Environmental Protection Agency (EPA) Substance
Registry System (SRS)
• Breast Imaging Reporting and Data System Atlas
(BI-RADS)
• Medical Dictionary for Regulatory Activities
(MedDRA)
• Systematized Nomenclature of Dentistry
(SNODENT)

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Data Standardization
• As HIM professionals search for ways to formalize
the myriad types of data contained in EHRs, it helps
to evaluate the different classifications and
terminologies based on certain desirable
characteristics.

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Desirable Characteristics of Clinical
Terminologies and Classification Systems
• Content
• Concept orientation
• Concept permanence
• Nonsemantic concept identifier
• Polyhierarchy
• Formal definitions
• Reject Not Elsewhere Classified (NEC)

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Desirable Characteristics of Clinical Terminologies
and Classification Systems (continued)
• Multiple granularities
• Multiple consistent views
• Context representation
• Graceful evolution
• Recognized redundancy

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Desirable Characteristics of Clinical Terminologies
and Classification Systems (continued)
• Licensed and copyrighted
• Vendor neutral
• Scientifically valid
• Adequate maintenance
• Self-sustaining
• Scalable infrastructure and process control

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Standards Development for Healthcare
• Several organizations are actively involved in
developing standards for healthcare
• Both private organizations and government
agencies such as ONC, CMS, FDA, the Agency for
Health Care Policy and Research, the Office of the
Assistant Secretary for Planning and Evaluation, and
the CDC work collaboratively in the development
and maintenance of these standards.

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Standards Development Organization
Examples
• AIIM (ANSI accredited standards development
organization)
• Accredited Standards Committee (ASC) X12
• American Dental Association (ADA)
• ASTM International
• European Committee for Standardization (CEN)
• Clinical and Laboratory Standards Institute (CLSI)
• Clinical Data Interchange Standards Consortium
(CDISC)

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Healthcare Standards Initiatives
• Legislative mandate Office of the National
Coordinator (ONC) of Health Information
Technology
• Department of Health and Human Services (HHS)
advisory committees
• With the introduction of Quality Payment Program models,
such as MACRA, The Health Information Technology for
Economic and Clinical Health (HITECH) Act’s Meaningful Use
initiative has been transitioned to be one of four components
of the Merit-Based Incentive Payment System (MIPS)

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Health Outcomes Priorities
• Improve coordination of Care
• ASTM (E2369-05e2)
• Identified a core data set for patient’s clinical summary—
Continuity of Care Record (CCR) a health record standard
specification
• Health Level Seven (HL7)
• Developed Clinical Document Architecture (CDA) which
provides an exchange model for clinical documents
• ASTM and HL7 Combined work
• Created Continuity of Care Document (CCD) which is an
implementation guide for sharing CCR patient summary data
using the CDA

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National Library of Medicine’s Role in
Healthcare Terminologies
• The National Library of Medicine (NLM) is the
world’s largest medical library.
• It collects materials in all aspects of biomedicine and
healthcare and is a standards-supporting and promoting
organizations
• Unified Medical Language System (UMLS) is the
NLM’s controlled vocabulary thesaurus that
contains three knowledge sources:
• UMLS Metathesaurus
• UMLS SPECIALIST Lexicon
• UMLS Semantic Network

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Role of HIM
• In order to reach the full potential of health
information exchange, HIM professionals must
participate in the development, implementation,
and maintenance of information systems that use
standards for collecting, reporting, and sharing
data.