- Lesson 5A: Data Standards
- Standards Evolution
- Key Data Standards
- ICD
- CPT (Current Procedure Terminology)
- Logical Observation Identifiers Names and Codes (LOINC)
- National Drug Code
- SNOMED-CT
- Activity
Lesson 5A: Data Standards
Data standards can be different from each other syntactically or semantically.
- Syntax : Structure difference, need translation.
- Semantic : Meaning difference, E.g. A doesn’t have the capacity to represent all the information in C.
Clinical data are often represented with different data standards (as shown above). It’s often very complicated to aggregate data from different sources.
Standards Evolution
- Physicians use ICD for diagnostic notes
- Labs and pharmacies have their own unique classifications. To coordinate care with each other, healthcare facilities need messaging standards between each other.
- When data exchange is needed (e.g. from physician to hospitals or vise versa), document standards play important role ( however, Document standards are hard to implement).
The above EDI/X12 and XML examples are showing the same test result. As we can see, that former is more compact, cryptic and hard to understand without training; while the letter is more human readable, descriptive and verbose.
Key Data Standards
- CPT (Current Procedure Terminology) and NDC (National Drug code) are U.S. Specific classifications
- ICD (The International Classification of Diseases) and CPT are most widely used because they are mostly required for medical billing.
- ICD, LOINC (Logical Observation Identifiers Names and Codes) and SNOMED (The Systematized Nomenclature of Medicine) are international ontologies.
ICD
- the U.S. is still using ICD-9 while the world is using ICD-10.
- The U.S. is set to adopt ICD-10 in 2015 when ICD-11 is about out. Some are proposing the idea of skipping ICD-10.
- ICD-10 provides more codes for more information (e.g. laterality of breast cancer)
- ICD is classification prior ICD-10. ICD-10 and the following versions are moving to ontology.
CPT (Current Procedure Terminology)
- CPT is updated annually by the American Medical Association. It classifies all the medical procedures and is required for all medical billings.
- There are three code category for widely performed procedures, quality and performance metrics and new or experimental procedures.
- For each code, there are Full, Medium and Short descriptions (see below).
- CPT code can be very detailed and specific (e.g. Psychiatry visits by length or size of removal tissue for a procedure)
- Billing personal must be trained to be able to select the correct codes.
Logical Observation Identifiers Names and Codes (LOINC)
- it was created and is maintained by the Regenstrief Institute
- LOINC provides codes for lab results and clinical observations
- LOINC provides detailed information about an observation with it’s names which can be divided into 7 subparts (See slide below).
National Drug Code
- maintained by FDA.
- 10-digit,3-segment structure indicates the vendor, the drug and the packaging.
SNOMED-CT
- Created by NIH for pathology, CT is specifically for clinical medicine. It is now distributed by the International Health Terminology Standards Development Organisation (IHTSDO)
- It’s always an ontology
- It’s complex
- 9-digital ID and human readable concept names.
- It has hierarchy (shown below)
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Relationship links expressed by “ is a ”.
Activity
- Click on the link below to get a copy of the sample CCD: Sample HealthVault Continuity of Care Document (CCD). Review the sample CCD carefully and answer the three questions below.
2015-09-21 初稿 至ICD slides
2015-09-22 补充完全