E-Health Systems

Data Standardization
Clinical Classifications & Terminologies
Dr Asif Syed,
MD MPH
Data
Unstructured facts that are available in different forms
Information
Structured and comprehensible collection, aggregation,
analysis and presentation of data
Types of
Healthcare
Information
Patient Specific
Clinical Administrative
Combined
Population Specific
Clinical Administrative Combined
Comparative
Knowledge
Based
Summary
E-Health
Use of Electronic
Processes and
Communication in
Healthcare
E-Health
EMRs
Decision Support Systems
E-Prescribing
Administration
Procurement
Reporting
Drug Interactions
TeleHealth
Repositories & Registries

E-Health in
Public Health
Reporting
Data Collection & Trending
Audit
Data Analytics
Drug Interactions
TeleHealth
Repositories & Registries

M-Health
Use of Mobile
Technologies,
Communications, and
Computing for Health
Services and Information
with the Key Goal of
Improving Personal and
population health
M-Health in Public
Health
Dissemination of Health
Information
Remote Data Collection
Consumer Interaction Point for
Location- Based Health
Information
Telehealth
Why Standardized Data
Representation?
Data can be more useful if it:
is recorded at the appropriate level of detail (not forced to be
either too general or too specific)
is consistent over time and across boundaries
can be transmitted without loss of meaning
can be aggregated at more general levels, and along multiple
different perspectives
can be interpreted by automated systems
can be employed by the computer to support good clinical
decision making
With permission, from Dr Spackman
Support Patient Care:
Safety
Effectiveness
Clinical Decision Support
Timeliness
Efficiency
Implementation of National Agenda and Policies
Organizational Management
AND
Too much variation in
representation of clinical
expressions
Angina Anginal syndrome Stenocardia Cardiac Angina Angina Pectoris
Angina
All this has to be tracked, analyzed and reported
Correctly and consistently despite of variation in detail described

Options to capture those
variations:
Classifications
Local data sets
Legacy term sets
Clinical terminologies

Why Code?
Facilitate retrieval of information
Facilitate data aggregation
Reimbursement and Billing
Facilitates automated queries
Facilitates ordering
Facilitates inventory


Terminologies/Classifications are required for gathering
data by developing computerized applications for;
Analyzing data
Billing
Clinical Decision support
Coding data
Data exchange
Data interoperability
Documentation
EMRs
Exchange data
Indexing data
Measuring data
Monitoring data
Navigating data
Procurement
Querying data
Recording patient data
Reporting
Reporting data
Research
Retieving data
Retrieving data
Reusing data
Sharing data
Statistics
Storing data
Transferring data


Public Health Applications of
Terminologies/Classifications are:
Analyzing data
Data exchange
Data interoperability
Exchange data
Indexing data
Measuring data
Monitoring data
Navigating data
Querying data
Reporting data
Research
Retrieving data
Reusing data
Sharing data
Statistics
Transferring data


Industry Standard:
Dr. Jim Cimino Desiderata

Concept orientation non vague, non
redundant and un-ambiguous meaning
Terminology content
Concept permanence
Nonsemantic identifiers
Polyhierarchy
Formal definitions
Recognizing redundancy
Reject NEC
Graceful evolution
Classification Systems
Group concepts
Concepts are categorized by where they fall in the
classification system
Category coding
Example:
M54.5 Low back pain
Loin pain
Low back strain
Lumbago NOS
International Classification of
Diseases (ICD)
Classification published by the World Health Organization
(WHO) originally to compare mortalities of nations
Used as diagnosis codes
ICD groups diagnoses into clinically useful categories
Rare for a category to contain just one diagnosis

International Classification of
Diseases (ICD)
Example:

M 50 Cervical disc disorders

M50.0 Cervical disc disorder with myelopathy
M50.1 Cervical disc disorder with radiculopathy
M50.2 Other cervical disc displacement
M50.3 Other cervical disc degeneration
M50.8 Other cervical disc disorders
M50.9 Cervical disc disorder, unspecified


International Classification of
Diseases (ICD) contd
Decoding in ICD only retains the category not the original
diagnosis
The ICD code does not retain information at its original level of
specificity
Categories are numbered in a sequence
Strict hierarchy
No complete names
Code determines place in hierarchy
Not Otherwise Specified (NOS)
Not Elsewhere Classified (NEC)


International Classification
of Diseases (ICD) contd
Categories and their contents can change as medical
knowledge changes
The code number assigned to a category might also
change
Difficult to compare data from one classification release
with that of another
International Classification of Diseases
9
th
Revision- Clinical Modification (ICD-
9 CM)
Developed in 1975 adding detail at the level of 4 and 5
(optional) digits (about 15,000 terms)
Implemented in 1979
Developed the procedure component (PCS) for inpatient
settings
Hands-On Understanding of ICD9-CM
Please visit
http://icd9cm.chrisendres.com/index.ph
p OR
http://www.eicd.com/EICDMain.htm
and browse through ICD data and try
some coding examples





ICD-9-CM Limitations

ICD-9-CM is not sufficiently robust to serve the health
care needs of the future
Due to the classifications age (30+ years) its content is no longer
clinically accurate
Need better data to drive changes needed in health care today
The structure is outdated and restrictive, with limited room to
add codes in many areas
ICD-9-CM update process cannot keep pace with changes
in health care
Non-comparability with State/National mortality data
Most developed countries have transitioned to ICD-10
Inability to compare at international levels


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ICD-9-CM to be
Replaced by ICD-10-CM in 2014
Compile statistics that are nationally representative
Calculate payment Medicare Severity-Diagnosis
Related Groups (MS-DRGs)
Adjudicate coverage billing and reimbursement
diagnosis codes for all settings
Assess quality of care
32
Review of ICD-10-CM Development
Requires Clinical Modification to;
Expand to include new concepts: emerging
diseases and more recent medical knowledge
Incorporate changes made to ICD-9-CM since ICD-
10 implementation
Expand distinctions in diagnoses for clinical utility
in all care settings
Also CMS developed a procedure code set for
inpatient use, ICD-10-PCS (with MS-DRG updates)
33
ICD-10-CM Development
Phases of development
Prototype developed under contract
20 Technical Advisory Panel members
Enhancements by NCHS
C&M minutes, providers & other users
Further enhancements based on public comments,
of 22 organizations/individuals
Pilot test, and updates based on comments
Updating with ICD-9-CM; more detail as appropriate
34
ICD-10-CM Development
Consultation with:
Physician groups, including:
Dermatology, Neurology, Obstetrics & Gynecology,
Orthopedics, Pediatrics, Psychiatry, Urology
Professional organizations, including:
Am. Diabetes Assn., Am. Hospital Assn., AHIMA, Am. Nurses
Assn., Natl. Assn. of Childrens Hospitals and Related
Institutions
Other users of ICD-9-CM
federal agencies, Workers Comp, epidemiologists,
researchers
35
ICD-10-CM Differences
Alphanumeric codes from ICD-10 (A00-Z99)
Addition of detail (e.g., laterality left and right)
Expanded codes (e.g., injury, diabetes)
Addition of sixth character, and seventh character
extensions (e.g., injuries, external causes; OB, also includes
trimesters)
Restructured categories (e.g., diabetes)
Combining certain codes:
Underlying cause & clinical manifestation codes
Deactivating procedure codes
Provide full code titles

36
Benefits of ICD-10-CM
and PCS
Updated medical terminology and structure for classification of
diseases and procedures
Allows easier comparison of mortality and morbidity diagnosis
data
Has more clinical detail
Provides better data for:
Measuring care provided to patients
Tracking for public health
Making clinical decisions
Identifying fraud and abuse
Using for epidemiological research
Designing payment systems/processing claims
Harmonization with other classifications:
DSM-IV (and V), ICD-O-2, nursing classifications

37
ICD-11
38
Diagnosis Related Groups (DRGs)
DRGs group ICD-9-CM codes into even larger groups for
reimbursement purposes
Adequate for billing, but not for the patient
What was the original diagnosis?
Complex coding logic
Based on ICD-9 CM Diseases and Procedures


DRG Examples: Pneumonia
75 Respiratory disease with major chest operating room procedure, no major complication or
comorbidity
76 Respiratory disease with major chest operating room procedure, minor complication or
comorbidity
77 Respiratory disease with other respiratory system operating procedure, no complication or
comorbidity
79 Respiratory infection with minor complication, age greater than 17
80 Respiratory infection with no minor complication, age greater than 17
89 Simple Pneumonia with minor complication, age greater than 17
90 Simple Pneumonia with no minor complication, age greater than 17
475 Respiratory disease with ventilator support
538 Respiratory disease with major chest operating room procedure and major complication or
comorbidity
539 Respiratory disease, other respiratory system operating procedure and major complication or
comorbidity
540 Respiratory infection with major complication or comorbidity
631 Respiratory infection with secondary diagnosis of bronchopulmonary dysplasia
740 Respiratory infection with secondary diagnosis of cystic fibrosis
770 Respiratory infection with minor complication, age not greater than 17
771 Respiratory infection with no minor complication, age not greater than 17
772 Simple Pneumonia with minor complication, age not greater than 17
773 Simple Pneumonia with no minor complication, age not greater than 17
798 Respiratory infection with primary diagnosis of tuberculosis
Clinical Terminology
Captures information recorded and/or used as part of the
process of providing a health care service
Allows entity coding that retains more detailed medical
information
A set of descriptions (human readable terms)
With associated codes
Example term and code:
Back pain
419258005

Clinical Terminology
Summarizes medical information
Facilitates use of medical data
Selective retrieval for aggregation and analysis (e.g. How
many new cases of breast cancer have we seen this
month? Is this persons blood sugar improving?)
Automated reasoning (i.e. clinical decision support)
SNOMED CT: A Standardized
Clinical Terminology
A clinical terminology covering diseases, clinical findings, and
procedures and others clinical areas
Allows for a consistent way of indexing, storing, retrieving and
aggregating clinical data across specialties and sites of care
Helps to structure and computerize the medical record,
reducing the variability in the way data is captured, encoded
and used for clinical care of patients and research


SNOMED CT: A Standardized Clinical
Terminology

Provides codes with explicit formal definitions of
their meaning
Can be implemented in software applications to
represent clinically relevant information

SNOMED CT has reference
properties
SNOMED CT is a clinical terminology with reference
properties
Reference properties are features that focus on data
retrieval, aggregation, and analysis
Reference properties
Relationships/logical definitions
Comparing SNOMED to Other
Terminologies
Administrative and statistical terminologies such as ICD
and CPT
May force data to be coded at a level that is too general
Require use of arcane or non clinical terminology

SNOMED CT allows coding
At the appropriate level of clinical detail
Uses clinically appropriate terminology
Facilitates reuse of data for research, decision support and
outcomes analysis
MeSH
Medical Subject Headings
National Library of Medicine
Indexing the medical literature
UMLS
The purpose of the [Unified Medical Language System] is to
improve the ability of computer programs to
understand the biomedical meaning in user inquiries
and to use this understanding to retrieve and integrate
relevant machine-readable information for users.

CPT
Current Procedural Terminology
Developed and owned by AMA
Required for procedure reimbursement
Required for physician visit reimbursement (E&M Coding)
CPT Examples:
76090: Unilateral mammography
76091: Bilateral mammography
76092: Screening mammography, bilateral (two view film study of
each breast)
76096: Mammographic guidance for needle placement, breast (e.g.,
for wire localization or for injection), each lesion, radiological
supervision and interpretation
76085: Digitization of film radiographic images with computer analysis
for lesion detection and further physician review for interpretation,
screening mammography (List separately in addition to code for
primary procedure)
76645: Ultrasound, breast(s) (unilateral or bilateral), B-scan and/or
real time with image documentation
Others:
Loinc
RxNorm


Current National
and International Focus
for the Representation of
Healthcare Data

Current Health IT Initiatives
Focus on standardizing code sets
Emphasis on having a defined set of code sets and terminologies
that can be used for various needs
Focus on interoperability and exchange of data
Desire to have code sets and terminologies that can relay data and
information for multiple purposes
Interest in using SNOMED CT, LOINC, RxNorm for more granular
clinical data
Administrative classifications
Local data sets
Legacy term sets
Clinical Terminologies
US
Adoption of EMRs - US
Clinical Terminologies
HITSP
ACA
ARRA
Meaningful Use
Adoption of EMRs - US
ACA - Meaningful Use
Recommendations from different
work groups within the ONC are
leaning towards the use of Clinical
Terminologies like SNOMED CT,
Loinc etc with no role for
classifications within the clinical
space
UK
Adoption of EMRs - International
Clinical Terminologies
Australia Canada Others
Terminology
Adoption of EMRs - International
WHO- ICD- 11
Interoperable Logic Based Computable
Terminological System
fine needle aspiration biopsy

48635004
Poly
Hierarchy
Meaningless
identifiers with no
limitations
Synonymy
Details based on logical
Definition
Capability of Post
Coordination
Hierarchies and data is
defined and processed using a
classifier or a reasoner not by
hand


Thanks