Coding and Standards in Health Informatics

Coding and Standards in Health Informatics

Dr Farzad Jahedi, MD, MSc May 2018

Methods

Collection

Protocols

Exchange

Terminologies

Storage

Specifications

Retrieval

Information health care applications

Healthcare Data Standards medical records medications radiological images payment and reimbursement medical devices and monitoring systems administrative processes

Standardizing health care data

Data elements

Determination of the data content to be collected and exchanged

Data interchange

Standard formats for electronically encoding the data elements

Terminologies

Medical Terms & Concepts

Knowledge

Standard methods for electronically representing

formats

Representation

used to describe, classify, and code the data elements

medical literature

Interchange standards

Document architectures

Information models

Data Expression Languages & Syntax that describe the relationships

among the terms/concepts

decision support

clinical guidelines

Data Elements Objects that can be collected, used, stored patient name

gender, and ethnicity

Diagnosis

primary care provider

laboratory results

Data Types data types

Date Time Numeric Currency

date of each encounter

each medication

Datasets

Define their form

Simple

Clinical information systems Application programs

Data elements grouped together

For

comparability &

interchange,

data types must be

universal

& carried through all uses of the data

Complex data types

Names Addresses

For: Measuring outcomes Evaluating quality of care Reporting on patient safety events

Primary Areas which need Standards Data interchange

Terminologies

Knowledge representation

facilitate

Message format

Data collection

Document architecture

Retrieval of relevant

Clinical templates User interface Patient data linkage

at the point of care

data, information, and knowledge (i.e., evidence)

Data reuse for

multiple purposes (such as

automated surveillance, clinical decision support, and quality and cost monitoring)

Biomedical literature

knowledge bases Evidence-based practice

linkage for enhanced access to medical knowledge bases

Data Interchange Standards

STANDARD

Data Interchange Standards Message Format Standards

Document Architecture

Facilitate interoperability: • Common encoding specifications

A method for Health Level Seven [ representing messaging, electronically clinical data

User Interface

HL7

• Information models for defining relationships between data elements • Document architectures

Clinical Templates

HL7 V3 provides the The medical device ] [V2.x]to series for clinical data mechanism specify industry is well versed further constraints on in developing user the optionality of the interfaces Digital Imaging and Communications in Medicine data elements that make devices through the use of safer, more effective, Document Architecture [HL7 Clinical] for medical images templates that can be and easier to use by applied against V3 information employing ( ), a defined, complete National Council for Prescription Drug aPrograms [NCPDP] a message or voluntary standard document.text, object thatforcan images, sounds, for human factors retailinclude pharmacy messaging and other multimedia content design

DICOM

CDA

SCRIPT

Institute of Electrical and Electronics Engineers [IEEE] standards for medical devices

ANSI/AAMI HE74

Patient Data Linkage Health Insurance Portability and Accountability Act (HIPAA) Patient Safety Institute (PSI) for its project to link health care providers statewide, is based on the Visa credit card network system

Human Factors Design Process for Medical • Clinical templates for structuring data Logical Observation Identifiers, Names and Codes Devices— establishes tools and techniques to support the analysis, as they are design, testing, and evaluation ofresults both simple and complex systems exchanged [ ] for reporting of laboratory

LOINC

Healthcare Standard Development Organisations

The International Classification of Disease (ICD) published by the World Health Organization

To allow morbidity and mortality data to be collected from around the world in a standard format structured into 21 chapters I, II, III, IV, V, VI, VII, VIII, IX, X, XI, XII, XIII, XIV, XV, XVI, XVII, XVIII, XIX, XX, and XXI

Diseases associated with body systems are found in Chapters VI to XIV Chapters I-V, XV-XVII and XIX cover special diseases

Why?

ISO’s Open Systems Interconnect (OSI) model Layer 7 – Application Layer 6 – Presentation Layer 5 – Session Layer 4 – Transport Layer 3 – Network Layer 2 – Data-link Layer 1 – Physical

 The only domain-specific aspect  Semantics or meaning of what is exchanged

various aspects of technical interoperability

HL7 V2 • Message Syntax

• describes the overall structure of messages and how the different parts are recognized

• Data Type

• Each message is composed of segments in specified sequence • each of which contains fields also in a specified sequence • these fields have specified data types

Some of commonly used segments MSH  Message Header PID  Patient Identification Details PV1  Patient Visit OBR  Request and Specimen Details OBX  Result Details Z-segment

MSH  Message Header

Data Types • Simple Data Types • • • • • • • • •

DT (date)  YYYY[MM[DD]]. DTM (date/time)  YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/–ZZZZ] FT (formatted text) embedded formatting commands ID a value from a HL7-defined table. IS a value from a user-defined table. NM (numeric) numeric values SI (set ID) gives the order of a segment instance within a message ST (string) short strings up to 200 characters. TX (text) longer texts up to 64 K characters.

• Complex Data Types • • • •

Coded values Identifiers Names Addresses

abstract syntax of the HL7 V2 message • MSH • PID • PV1 • OBR • {OBX}

Message header Patient Identification Details Patient Visit Results header Results detail (repeats) MSH|delimiters||sender|||dateTime||messageType|messageID |processingStatus|syntaxVersion PID|||patientID^^^source^IDtype||familyName^givenName||d ateOfBirth|sex|||streetAddress^addressLine2^^^postCode PV1|||patientLocation|||||patientsGP OBR|||accessionNumber|testCode^testName^codeType|||speci menDate||||||||specimenSource^^^bodySite^siteModifier |requester OBX||valueType|observableCode^observableName|observatio nSubID|valueCode^valueText^valueCodeType|||abnormalFl ag|||result status OBX ...

MSH|^~\&||^123457^Labs|||200808141530||ORU^R01|123456789|P|2.4 PID|||123456^^^SMH^PI||MOUSE^MICKEY||19620114|M|||14 Disney Rd^Disneyland^^^MM1 9DL PV1|||5N|||||G123456^DR SMITH OBR|||54321|666777^CULTURE^LN|||20080802||||||||SW^^^FOOT^RT|C987654 OBX||CE|0^ORG|01|STAU||||||F OBX||CE|500152^AMP|01||||R|||F OBX||CE|500155^SXT|01||||S|||F OBX||CE|500162^CIP|01||||S|||F

HL7 message ASCII

Report from Lab123457, 15:30 14-Aug-2008, Ref 123456789 Patient: MICKEY MOUSE, DoB: 14-Jan-1962, M Address: 14 Disney Rd, Disneyland, MM1 9DL Specimen: Swab, FOOT, Right, Requested By: C987654, Location: 5N Patients GP: Dr Smith (G123456) Organism: STAU Susceptibility: AMP R SXT S CIP S

DG1 - diagnosis segment to transmit one patient diagnosis Additional DG1 segments are sent for separate diagnoses.

HL7  and  ICD

If there is a new diagnosis, or a change in any of the diagnoses, they should all be resent. Diagnosis coding method ICD9 is the only valid coding system supported by the interface.

Seq

Len Fmt Opt

Element Name

0

3

R

Segment ID = "DG1"

1

4

SI

O

Set ID – Diagnosis

This field should contain "I9" if the diagnosis is an ICD9 Otherwise, the field should be omitted.

2

2

ID

R

Diagnosis coding method

3

8

ID

O

Diagnosis code

4

40

ST

R

Diagnosis description

Diagnosis code If the ICD9 code is available, it should be placed here.

5

14

TS

R

Diagnosis date/time

6

2

ID

R

Diagnosis/DRG type

7

4

ST

O

Major diagnostic category

Diagnosis description This field should contain the diagnosis description (i.e., either the one related to the ICD9 code, or free text).

8

4

ID

O

Diagnosis related group (DRG)

9

2

ID

O

DRG approval indicator

10

2

ID

O

DRG grouper review code

11

2

ID

O

Outlier type

Diagnosis/DRG type Valid types include "ADMITTING", "INTERIM" and "FINAL"

12

3

NM

O

Outlier days

13

12

NM

O

Outlier cost

14

4

ST

O

Grouper version and type

Sample of Integration using HL7 Broker HL7 HL7

txt Medical Imaging Application

IS

txt

HIS

PACS

What you should learn about HL7 • Why Interoperability Standards? • Why HL7?

• Message Types?

• HL7 V2 Structure?

• Trigger Events?

• Message Syntax?

• Data Types?

• Segments?

• Delimiter?

• Fields?

• HL7 Broker?

• Components / Subcomponents?

DICOM

Digital Imaging Communications in Medicine

ISO Reference Model

APPLICATION

Upper Layers (DICOM) Lower Layers

PRESENTATION SESSION

File Transfer, E-mail, HTTP Data Formatting, Compression,Encryption Synchronization,Comm. Management

TRANSPORT

End-to-End communication

NETWORK

Internetworking

DATA LINK

LLC MAC

PHYSICAL

Ethernet, FDDI, etc.

Fiber, Coax, UTP, µWave

Summary of DICOM Features • NETWORK PROTOCOL

DICOM incorporates negotiation to permit nodes to agree on the functions to be performed

• MESSAGE ENCODING

DICOM defines 24 data types (V2.0 had 4) DICOM message encoding includes JPEG compression (17 variants) DICOM includes encapsulated image and multi-frame syntaxes DICOM supports multiple character repertoires

• OBJECT DATA MODEL

DICOM is based on a completely specified data model DICOM includes a robust UID mechanism

• DATA DICTIONARY

DICOM includes a large number of new data elements

Summary of DICOM Features cont. •SERVICE CLASSES

DICOM defines classes of service for specific applications (e.g. image management, printing) and conformance levels

• Off-Line Media Support

DICOM defines a directory structure and media profiles

• CONFORMANCE

DICOM requires conformance statements and contains detailed conformance requirements

PACS

RIS SERVER

Modality

MIRTH SERVER

CONSOLE

MULTIMEDIA REPOSITORY

DICOM REPOSITORY

SHARED FOLDER User

Radiologist STATION

Radiologist STATION Data MANAGER Radiologist STATION

Terminologies

Core Phenomena of Clinical Practice

Diagnoses, Symptoms, and Observations (e.g., medical diagnoses, nursing diagnoses, problem list);

Interventions, Procedures, and Treatments, including those focused on prevention and health promotion

Health outcomes (e.g., disability, functional status, symptom status, quality of life)

2003

CORE TERMINOLOGIES

Systemized Nomenclature of Medicine, Clinical Terms (SNOMED CT)

developed by the College of American Pathologists, SNOMED CT is an inventory of medical terms and concepts for human and veterinary medicine arranged in a multihierarchical structure with multiple levels of granularity and relationships between concepts. Many nursing codes have been incorporated into the terminology. It is a comprehensive medical vocabulary and classification system with over 300,000 fully specified concepts and 450,000 supporting descriptions.

Logical Observation Identifiers, Names, and Codes (LOINC)

Developed by the Regenstrief Institute, LOINC provides a set of universal names and numeric identifier codes for laboratory and clinical observations and measurements in a database structure without hierarchies whereby the records appear as line items. Currently, there are over 30,000 codes in the LOINC database.

RxNORM (“normalized” notations for clinical drugs)

developed in a joint project between the National Library of Medicine and the Veterans Health Administration to create a semantic normal form for a clinical drug, designed to represent the meaning of an expression typically seen in a physician’s medication order. When released, RxNORM will represent the 81,165 clinical drugs in the Unified Medical Language System.

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. UMDNS contains 17,221 terms.

Relationships

Descriptions

Concepts

The Systematized Nomenclature of Medicine (SNOMED)

SNOMED-CT Simple Sample “Heart”

SEMANTIC SEARCH

Procedures

Semantics

Pharmacology

Diseases Clinical Organism

SNOMED CT ONTOLOGY

Anatomy

Synonyms

Heart Notebooks

Books

3D Body

Vector Body

https://bioportal.bioontology.org/ontologies/SNOMEDCT

SUPPLEMENTAL TERMINOLOGIES Unique Ingredient Identifier (UNII)

developed by the Food and Drug Administration (FDA) as a method for coding molecular entities through their active and inactive ingredients.

Medical Dictionary for Drug Regulatory Affairs (MedDRA)

Developed by the International Conference on Harmonization to harmonize international regulatory requirements for the drug development, marketing approval, and safety monitoring process. It provides a comprehensive vocabulary and coding system of 70,000 terms for safety-related events and adverse drug reactions.

Medicomp Systems Incorporated (MEDCIN)

a proprietary medical vocabulary designed as a controlled vocabulary of pre-correlated clinical concepts from its nomenclature and associated knowledge base containing 175,000 clinical findings and diagnoses and 600,000 synonyms. It is considered a “user interface” terminology.

International Society for Blood Transfusion (ISBT)

developed by the American Blood Commission as a bar-code labeling specification for blood products. It was designed to capture additional and more complex information regarding the identification and content of blood and blood products on the label and to make that information universally accessible to the international blood banking community.

Diagnostic and Statistical Manual for Mental Disorders (DSM-IV)

Developed by the American Psychiatric Association to provide a terminology and set of diagnosis codes for mental health conditions.

Pharmacy knowledge bases

developed by the vendor community, including FirstDatabank, Medi-Span, and Multum. These systems provide information about drug interactions, allergies, contraindications, drug–laboratory inferences, toxicology, and the like

HIPAA Terminologies International Classification of Diseases (ICD), Clinical Modifications (CM)

U.S. government expansion of the World Health Organization (WHO) coding system. ICD-9 CM provides approximately 15,500 terms and codes for diagnosis and inpatient services/procedures. The U.S. clinical modification of ICD-10 was published in late 2002. ICD-10 CM contains about 50,000 terms.

National Drug Codes (NDCs)

the standard code set developed by suppliers and maintained by the FDA to identify and regulate drugs and biologics marketed in the United States. The codes also are used for reimbursement of medicines. NDCs are employed for the approximately 10,000 drugs approved for use in the United States.

Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedure Coding System (HCPCS) Developed and maintained by the American Medical Association. CPT is the official code set for physician services in outpatient office practices. HCPCS provides codes for products, supplies, and services not in the CPT codes (e.g., ambulance service) and local codes established by insurers and agencies to fulfill claims processing needs. Together, CPT and HCPCS provide 7,300 terms.

Current Dental Terminology

developed by the American Dental Association to represent data related to dentistry.

Knowledge Representation Computer-interpretable Guidelines

creation, dissemination, and application of computer-interpretable medical knowledge

Summary Data interchange Message format HL7 v2.x DICOM SCRIPT

LOINC IEEE

Terminologies SNOMED, Clinical Terms CT

Computer-interpretable Guidelines

Laboratory LOINC

Guideline Interchange Format (GLIF)

Document architecture CDA

RxNORM

Clinical templates HL7 v3.x

National Drug File Clinical Drug Reference Terminology (NDF RT)

User interface HE74

Food and Drug Administration’s terminology

Patient data linkage HIPPA

PSI

Knowledge representation

ICD-10

GELLO (Guideline Expression Language, Object-Oriented)

KnowledgeBases MEDLINEplus Cochrane Collaboration

Implementation of Data Standards

Issues that should be considered when establishing a mechanism for compliance

Vendor readiness Organizational readiness Cost of compliance tools Unresolved issues related to terminologies and coding Identifiers for providers and patients Interpretation of the implementation guides and standard specifications.