HEALTHCARE DATA STANDARDS

INTRODUCTION

• Standards are critical components in the development and implementation of an

electronic health record (HER). The effectiveness of healthcare delivery is dependent on
the ability of the clinicians to access critical health information when and where it is
needed.
 NEED FOR HEALTHCARE DATA STANDARDS

Data standards as applied to healthcare include:

• Methods
• Protocols

• Terminologies

• Specification for the collection

• Exchange

• Storage
• Retrieval of information associated with healthcare applications (medical records, medications, radiological images,
payments and reimbursement, medical devices, monitoring system and administrative process)
 TERMINOLOGIES

There have been great advances in the ability of the computers to process natural
language, most communication between health information systems relies on the
use of structured vocabularies, code sets, and classification systems represent
healthcare concepts.

Standardized terminologies enable data collection at the point of care, and retrieval
of data, information, and knowledge in support of clinical practice.
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES
AND RELATED HEALTH PROBLEMS: 9TH REVISION AND CLINICAL
MODIFICATIONS (ICD-9-CM)
• is the latest version of a mortality and morbidity classification that originated in 1893

• widely accepted, used in the healthcare industry and has been adopted for a number of purposes
- Data collection
- Quality of care analysis
- Resource utilization
- Statistical reporting

> it is the basis for diagnostic related group which are use extensively for hospital reimbursement.
> internationally used for death tabulation
INTERNATIONAL STATISTICAL CLASSIFICATION OF
DISEASES AND RELATED HEALTH PROBLEMS:10TH
REVISION
• -is the most recent revision of the ICD classification system for mortality and morbidity
which is used worldwide
SYSTEMATIZED NOMENCLATURE OF HUMAN
VETERINARY MEDICINE INTERNATIONAL, CLINICAL
TERMS
• (SNOMED) comprehensive multiracial nomenclature and classification system for
indexing human and veterinary medical vocabulary, including signs and symptoms,
diagnoses and procedures.
 RXNORM

Is a clinical drug nomenclature produced by NLM in consultation with:

• (FDA) food and drug administration
• (VA) department of veterans affairs
• RxNorms provides standard names for clinical drugs (active ingredient+ strength+dose form)
and for those forms as administered.
• It provide links from clinical drugs to their active ingredients, drug component (active
ingredient+strength) and some related brand names.
UNIFIED MEDICAL LANGUAGE SYSTEM

• (UMLS) consist of metathesaurus of terms and concepts from dozen of

vocabularies: a semantic network of relationships among the concepts
recognize in the metathesaurus: and an information sources map of the
various biomedical database referenced.
INTERNATIONAL ORGANIZATION FOR
STANDARDIZATION
(ISO) Is an organization that develops and publishes standard internationally.

ISO 18104:2014 Health informatics — Categorical structures for representation of

nursing diagnoses and nursing actions in terminological systems

• this standard includes the development of reference terminology models

for nursing diagnosis and nursing actions and relevant terminology and
definitions for its implementation.
AMERICAN NATIONAL STANDARD INSTITUTE

>ANSI serves as the coordinator for voluntary standards activity

in the U.S
>also the U.S representative to ISO and is responsible for
bringing forward U.S standards to that organization
OBJECT MANAGEMENT GROUP

• (OMG) is representative of different approach to standard

development.
• is an international consortium of over 800 organizations,
primarily for profit vendors of information system technology,
who are interested in the development of standard based on
object oriented technologies.
Reference:

• http://karlrufosumatra.blogspot.com/2011/05/electronic-health-record-systems-us.htm