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Coordination of Terminologies and Classifications in Electronic Health Records

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  1. Coordination of Terminologies and Classifications in Electronic Health Records Sue Bowman, RHIA, CCS Director, Coding Policy and Compliance American Health Information Management Association

  2. EHR Interoperability • Interoperable health information exchange requires common medical language • Common medical language is represented by linked, standard terminologies and classifications

  3. EHR without Terminologies

  4. Organizational Decisionmaking Today’s Reality Patient Reimbursement Severity Measurement Medical Record Coding Disease Management & Registries Database Operational Decision making Statistics

  5. Organizational Decisionmaking Ideal Process Patient Reimbursement Coding Severity Measurement Medical Record SNOMED CT Disease Management & Registries Database Operational Decision making Statistics

  6. Terminologies & Classifications – Why Both? • Different roles and purposes • Terminology – “input” system • set of terms describing health concepts • “reference terminology” is an explicit, formal specification or ontology of concepts and the relationships linking them • Used to record detailed clinical information to support clinical care, decision support, outcomes research, and quality improvement • Classification – “output” system • Groups together similar diseases and procedures and organizes related entities for easy retrieval • Used for external reporting purposes, such as reimbursement and statistical and epidemiological data analysis

  7. Terminology (SNOMED) APGAR: cardiac score, respiratory score, muscle tone, reflex response, color, etc. Classification (ICD-9-CM) Final diagnosis : normal newborn Procedure: Circumcision Classifications and Terminologies Capture Different Levels of Clinical Detail

  8. Reference Terminologies • Reference Terminologies • SNOMED-CT • LOINC • NDF-RT • RxNorm

  9. Classification Systems • Classifications • ICD-9-CM • ICD-10-CM • ICD-10-PCS • ICD-O • ICF • ICPC • HCPCS

  10. Role of Mapping • “Mapping” is the process of linking content from one terminology to another or to a classification • Reference terminologies mapped to modern classification systems • Decrease administrative costs • Decrease time in revenue cycle • Increase specificity and accuracy of data • Maintain comparable data

  11. Map Development • Define use case (intended purpose) • Unidirectional vs. bidirectional • Testing and validation • Ongoing maintenance and updating

  12. Use Case Specification • Intended users must be clearly defined • Context of the use case is important • Multiple use cases are possible between the same 2 terminologies • Stating the map’s purpose is first step to defining scope, level of validation, and intended audience • Use case becomes framework for additional requirements for the map

  13. Mapping Principles • Understandable • All mappings have stated purpose and audience • Map documentation is complete, clear, and unambiguous • Mappings define source & target domain scope for the map

  14. Mapping Principles (con’t) • Reproducible • Mappings employ authoritative reference sources uniformly • Documentation defines all assumptions, heuristics, and procedures required to manage context and create map • All terminology developers move to compliance with sound principles of permanence and version management

  15. Mapping Principles (con’t) • Useful • Use cases are defined for map • Publication cycle is timely and linked to version change for source & target vocabularies • Agreement is reached for standards of knowledge representation in mapping

  16. Examples of Maps • ICD-9-CM 2005 to ICD-9-CM 2006 • ICD-9-CM Vol III to CPT (and vice versa) • DSM-IV to ICD-9-CM • SNOMED CT to ICD-9-CM • SNOMED CT to nursing terminologies • SNOMED CT to LOINC

  17. Mapping Issues • Different maps are needed for different use cases • There are no map development standards • Validation of map is critical • Mapping process is dynamic • Definition of “valid” map is needed • Managing context (patient characteristics, comorbid conditions, encounter data, etc.) is challenging • Complexity of coding rules for administrative reporting also creates challenges • Human review has not been eliminated • Map development is still in its infancy

  18. Other Harmonization Issues • Code set development/maintenance disparities • Need better coordination among code set developers and maintenance organizations to facilitate development of better maps • Harmonization of code set effective dates would facilitate map maintenance process • Continued use of outdated classification systems • Replacement of ICD-9-CM with ICD-10-CM/PCS would result in improved maps from terminologies

  19. Resources • AHIMA web site • www.ahima.org • AHIMA’s white paper titled “Coordination of SNOMED-CT® and ICD-10: Getting the Most Out of Electronic Health Record Systems” • http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027179.html