BINF 5130 ALL PPT - Healthcare Code Sets Clinical...

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© 2010 Healthcare Code Sets, Clinical Terminologies, and Classification Systems Chapter 1: Introduction
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© 2010 Coding of Healthcare Encounters Core HIM function Some say, the essence of HIM
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© 2010 Coding Futures Task Force AHIMA strategic initiative Likely futures of HIM professionals Must go beyond code assignment Enter broader areas – Data formalization – Concept representation – Mapping
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© 2010 Code Sets, Terminologies, and Classification Systems HIPAA Standard Code Sets ICD-9-CM (ICD-10-CM and ICD-10-PCS as of 10-1-2013) – CPT – CDT – NDC – HCPCS Terminologies and Classification Systems (EHR-related) – RxNorm – LOINC SNOMED CT – ICF
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© 2010 Lack of Shared Standards Increases paperwork and data collection burdens Reduces analytic potential of health data Little ability to make multiple uses or link data Limits usefulness of data collected
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© 2010 Need for Shared Data Standards Better agreement on common health data vocabularies Assurances of privacy Other issues surrounding electronic data transmission
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© 2010 IOM report “Patient Safety: Achieving a New Standard for Care” Standardization of data elements: – Defining what to collect – Deciding how to represent what is collected – Determining how to encode the data for transmission
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© 2010 Organization Instrumental in Data Standards Development and Implementation • ONC NeHC (formally AHIC) • CHI • HITSP • CCHIT Health IT Standards Committee Health IT Policy Committee
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© 2010 Terminology “A terminology is a set of terms representing a system of concepts.”
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© 2010 Vocabulary “A vocabulary is a collection of words or phrases with their meanings.”
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© 2010 Classification “A classification is a system that arranges or organizes like or related entities.”
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© 2010 Clinical Pertains to the practice of medicine, particularly as it relates to patients
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© 2010 Reference Pertains to the terms of a field itself, such as medicine or disease; however, it is not limited to the medical field
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© 2010 Interface Refers to communication between two entities, one of which is usually an electronic system
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© 2010 Controlled Pertains to how the terms included in a vocabulary are bound or limited
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© 2010 Ontology “Ontology in information science is a common vocabulary organized by meaning that allows for an understanding of the structure of descriptive information, which helps to facilitate interoperability.”
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© 2010 Reference Terminology “A reference terminology is a set of concepts and relationships that provides a common consultation point for comparison and aggregation of data about the entire healthcare process. A reference terminology is a form of ontology.”
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© 2010 Examples Clinical classification – ICD-10-CM Reference terminology – SNOMED CT Controlled classification – ICD-9-CM
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© 2010 Differences Vocabulary/terminology – provides a way to input
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  • Fall '16
  • Dr. Robert G. Stoll
  • Unified Medical Language System, Medical classification, SNOMED CT, classification systems, Healthcare Code Sets, clinical terminologies

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