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HIT Standards Committee Clinical Quality Workgroup and Vocabulary Task Force. Wednesday, August 17, 2011 Jim Walker and Jamie Ferguson, Chairs Karen Kmetik and Betsy Humphreys, Co-Chairs. 1. Vocabulary Task Force. Chair : Jamie Ferguson Kaiser Permanente

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hit standards committee clinical quality workgroup and vocabulary task force

HIT Standards CommitteeClinical Quality Workgroup and Vocabulary Task Force

Wednesday, August 17, 2011

Jim Walker and Jamie Ferguson, Chairs

Karen Kmetik and Betsy Humphreys, Co-Chairs

1

vocabulary task force
Vocabulary Task Force

Chair: Jamie Ferguson Kaiser Permanente

Co-Chair: Betsy Humphreys National Library of Medicine

Members

Donald Bechtel Accredited Standards Organization X12

Lisa Carnehan NIST

Christopher Chute Mayo Clinic

Bob Dolin HL7

Floyd Eisenberg National Quality Forum

Patricia Greim Veterans Affairs

John Halamka Harvard Medical School

Stan Huff Intermountain Healthcare

John Klimek NCPDP

Clem McDonald National Library of Medicine

Stuart Nelson National Library of Medicine

Marc Overhage Regenstrief Institute

Marjorie Rallins American Medical Association

Dan Vreeman Regenstrief Institute

Jim Walker Geisinger

Andrew Wiesenthal IHTSDO (SNOMED)

Federal Ex Officio

Chris Brancato HHS/ONC Greg Downing HHS

Doug Fridsma HHS/ONC Marjorie Greenberg HHS/CDC

Amy Gruber CMS

2

clinical quality measures workgroup
Clinical Quality Measures Workgroup

Chair: Jim Walker Geisinger Health System

Co-Chair: Karen Kmetik American Medical Association

Members

David Baker Northwestern University

Anne Castro BlueCross BlueShield of South Carolina

Christopher Chute Mayo Clinic

John Derr Golden Living, LLC

Bob Dolin HL7

Floyd Eisenberg NQF

Rosemary Kennedy Thomas Jefferson University

David Lansky Pacific Business Group on Health

Gene Nelson Dartmouth University

Eva Powell National Partnership

Philip Renner Kaiser Permanente

Danny Rosenthal Inova Health System

Joachim Roski Brookings Institution

Federal Ex Officio

Jon White, AHRQ

Aneel Advani, Indian Health Service, HHS

Patrice Holtz, CMS, HHS

TBD, CDC, HHS

3

project scope
Project Scope

Assign minimum necessary vocabulary standards to the fundamental concepts in the NQF’s Quality Data Model v3.0 (QDM) to enable effective expression of quality measures and interoperable electronic health record data elements

4

foundation concepts
Foundation Concepts
  • 1. Measures Development
    • Limit code sets used for measures.
    • Use of the code set may be limited to partial depth (e.g., a subset of ISO 639-2 for preferred language).
    • Future purpose-specific subsets of code sets will be needed.
  • 2. HIT Certification
    • Certified HIT shall be able to process all legal codes in the code set for a given concept (e.g., Adverse Effect).
  • 3. Meaningful Use (reimbursable)
    • Only code sets required in HIT certification shall be required for Meaningful Use reimbursement.
  • 4. Interim Transition Plans
    • End state targets are recommended for measure purposes. Some transition plans will be needed, are yet to be developed and will be presented to HITSC (more on this later)

5

recommended code sets
Recommended Code Sets
  • Adverse Drug Effect (allergy or non-allergy)
    • RxNorm for Medications (inactive ingredients to be added)
    • SNOMED CT for non-medication substances
    • SNOMED-CT for Adverse Effect

6

recommended code sets1
Recommended Code Sets
  • Patient Characteristics
    • ISO 639-2 for the patient’s Preferred Language
    • CDC PHIN-VADS (HL7) for Administrative Gender
    • CDC PHIN-VADS Race and Ethnicity
    • LOINC for assessment instruments (including tobacco use)
    • SNOMED-CT for appropriate responses to instruments (including patient preferences and behaviors)
    • Socio-economic Status - referred to CMS for clarification of request (in the absence of widely accepted typologies)
    • Payer Typology of the Public Health Data Standards Consortium

7

recommended code sets2
Recommended Code Sets
  • Communication
    • SNOMED-CT
  • Condition/Diagnosis/Problem (active and inactive)
    • SNOMED-CT
  • Device
    • SNOMED-CT
  • Non-laboratory Diagnostic Study
    • LOINC for specific study name
    • SNOMED-CT for appropriate findings
    • UCUM for specific units of measure
  • Encounter—”Patient-Professional Interaction” (not limited to billable events)
    • SNOMED-CT

8

recommended code sets3
Recommended Code Sets

9

  • [Patient] Experience
    • LOINC for assessment instruments
    • SNOMED-CT for appropriate responses
  • Family History
    • LOINC for assessment instruments
    • SNOMED-CT for appropriate responses
  • Functional status
    • ICF (International Classification of Functioning, Disability, and Health) for categories of function
    • LOINC for assessment tools
    • SNOMED-CT for appropriate responses
recommended code sets4
Recommended Code Sets

10

  • Health Record Components (element of a health IT application)
    • LOINC for naming of the components and their relationships
    • HL7 for messaging among systems
  • Intervention (forms one end of a spectrum with Procedures)
    • LOINC for interactions that produce an assessment or measurable results
    • SNOMED-CT for appropriate results and interventions that do not produce measurable results (e.g., counseling)
  • Adverse Effect other than Allergy (intolerance)
    • RxNorm for medications and inert ingredients
    • SNOMED-CT for Non-medication substances
    • SNOMED-CT for Adverse effects
recommended code sets5
Recommended Code Sets

11

  • Laboratory tests
    • LOINC for test name and its results
    • SNOMED-CT for appropriate results
    • UCUM for units of Measure
  • Medication (including vaccines)
    • RxNorm for medications
    • CVX for vaccinations as standard vocabulary (in some contexts vaccinations are treated as medications, in others they are treated separately)
  • Physical Exam
    • LOINC for assessment instrument
    • SNOMED-CT for appropriate responses
recommended code sets6
Recommended Code Sets

12

  • [Patient] Preference
    • LOINC for assessment instruments
    • SNOMED-CT for appropriate responses
  • Procedure
    • SNOMED-CT
  • Risk Evaluation
    • LOINC for evaluation instruments
    • SNOMED-CT for appropriate responses
  • Substance
    • SNOMED-CT
recommended code sets7
Symptom

SNOMED-CT

System resources

LOINC for staffing resources

HL7 for EHR functions

SNOMED-CT for equipment

Transfer

SNOMED-CT

Recommended Code Sets

13

action
Action

Accept the recommended code sets for QDM concepts

14

next steps
Next Steps

Transition Plans — to be presented at September 28th HITSC meeting, will address:

Interim use of code sets currently employed in quality measures

6 concepts have code sets required in MU Stage 1 (3 of these would change with recommended sets – e.g., using ICD, CPT, HCPCS)

Transition time required for:

Testing of recommended code sets

Measure developers to incorporate new recommendations into exiting, retooled, and de novo measures

Incorporation into certification criteria

15

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