The Importance of Standards in Information Technology Order Instructions: For your selected organization (Salisbury, NC VA), examine the standards of the applications the IT department uses. In your discussion include the importance of the standards and any issues surrounding the standards (e.g., definitions consistent with other organizations or across applications).
There is a need to describe healthcare concepts in a consistent manner. We as humans are able to assimilate, without confusion, many variations of descriptions. Computers, on the other hand, are very poor at recognizing concepts from inconsistent descriptions.
A preferred term is an agreed-upon short description of a concept, and a concept is an image created by the words that describe it. However, in some cases, a definition of a concept may still be needed. This is because, too often, the wording of a preferred term means something different to different users.
A unique identifier (or code) for each concept is required. Anything would do, as long as it is unique and suitable. If a preferred term is used, its description should not be changed; however, it does sometimes happen. Accordingly, a preferred term is generally not suitable as a code. In fact, words are not efficient ways to store identifiers in computers, as the computer may be required to store an identifier many times. Therefore, the code should be reasonably “compact,” preferably a “number” of some sort. Using a number is not an issue, because the computer can always display equivalent descriptive words that are seen by the users.
Coding is the process of matching a healthcare entity to a term in terminology and assigning it a code. The terminology may be called a coding system. Sometimes rules are offered to improve the accuracy of coding. These rules are commonly known as standards.
In this module, we will explore the language of Health Informatics. We will examine database fundamentals and types of health information data and records, and explore standards used to ensure the information is understood across various systems and disciplines.
This module covers a large amount of area and material. Do not get overwhelmed by trying to dig too deeply into the technical aspects. Indeed, each area can be an entire field of technical study of its own. Instead, focus on the concepts, application, and purpose surrounding structured data and standards as they relate to healthcare information.
Presentations and Required Reading
• Carefully read through the following material, which describes the fundamentals of databases, and their structure and function. Fundamental Database Characteristics1
• Eric McCreath provides a well-illustrated and concise overview of database fundamentals in the following presentation: Database Basics Presentation2
• The following slide presentation identifies various types of medical data and records. Presentation by Peter Szolovits, MIT (February 2002). Nature of Medical Data3
• There are many standards guiding the format and use of healthcare-related information. The following is a comprehensive list and review of these standards. It is not necessary to memorize every one of them. Instead, just get a sense for the vast number of standards that exist. Pay particular attention to those standards that reference Health Level Seven (HL7) and Unified Medical Language System (UMLS). Review of Healthcare Information Standards4
• The following is a list of Standards Organizations. Standards Development Organizations5
• Read through this overview of the Unified Medical Language System. UMLS6
• Jiang Bo provides a good overview of Health Level Seven (HL7) in this presentation. HL77
Sources for Presentation Material Referenced Above
1Beaumont, R. (2000). Database and Database Management Systems. Retrieved from Fundamental Database Characteristics
2McCreath, E. (2002). Lecture Notes for COMP1200: Perspectives on Computing, Information Systems Database Basics. Retrieved from Database Basics Presentation
3Szolovits, P. (2003). Nature of Medical Data. MIT, Intro to Medical Informatics: Lecture-2. Retrieved from http://groups.csail.mit.edu/medg/courses/6872/2003/slides/lecture2-print.pdf
4Blair, J. S. (1999). An Overview of Healthcare Information Standards, IBM Healthcare Solutions. Retrieved from Review of Healthcare Information Standards
5Health Level Seven: Links to Standards Developers. Retrieved from Standards Development Organizations
6Unified Medical Language Fact Sheet. (2003). National Library of Medicine: Office of Communications and Public Liaison. Retrieve from http://www.nlm.nih.gov/pubs/factsheets/umls.html
7Bo, J. (2003). Health Level Seven Overview Presentation. Bioinformatics Institute. Retrieved from HL7
The Importance of Standards in Information Technology Sample Answer
Standards in IT
Standards of Applications used in IT departments at Salisbury, NC, VA
Health data exchange and interoperability has been enhanced by health information technology. To perform aan ccurate data exchange, the information technology standards are used to facilitate interoperability through a common code to encode health information. The standards are perceived as the agreed health information “language” that can be interpreted accurately by a multiple system (Depart of Veterans Affairs, 2012). When developing standards in this healthcare facility, two main concepts are put into considerations including a) syntax-grammar rules for the defined clinical language so that the electronic information can be exchanged accurately with minimal deconstruction; and b) semantics- to ensure that the information components are coded appropriately and their meaning can be understood (Moen & Mæland Knudsen, 2013).
The standards used in this healthcare facility are guided by the Veterans Health Administration (VHA) handbook which contains all the procedures of managing the clinical coding process in the facility. The guiding framework consists of guidelines including the CPT Assistant, Current Procedural Terminology (CPT), Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, Healthcare Common Procedure Coding System (HCPCS) and International Classification of Disease Clinical Modification (ICD-CM). Physical observations, clinical assessments and treatment plans are essential elements that require to be documented. There are various data content standards that have been developed to create a framework of optimal health and efficient exchange of information. This is actually vital with the increase focus on use of Electronic Health records (Moen & Mæland Knudsen, 2013).
There is an increased need to create standards and definitions of individual terms in this clinic, coupled with appropriate content standards in order to uniformly capture and collect essential framing structures that define appropriate clinical concepts. This will facilitate effective sending of patient information back and forth between the relevant stakeholders. At this health care facility, the commonly used frameworks for standards in electronic health record system includes National Council for Prescription Drug Programs (NCPDP), Continuity of Care Record/Document, SNOMEDCT, Digital Imaging and Communications in Medicine (DICOM), RxNorm, ICD-9-CM, HL7, HIPAA, Current Procedural Terminology (CPT) and ICD-10-CM/PCS (Moen & Mæland Knudsen, 2013).
The use of these standards ensures meaningful performance, monitoring and outcomes evaluation. In addition, the standards allows for consistent, evidence based care through clinical decision support. The National Quality Forum’s Quality Data Model (QDM) offers the potential for precise, well defined, and universally accepted electronic measures that can be used for comparison purposes and for improvement of care (Beaumont, 2000).
The Importance of Standards in Information Technology and Advantages of the standards
The advantages of these standards are that they facilitate a continuation of accuracy through coding data that is reliable and accurate in planners, researchers and clinicians. In addition, the standardized terminology facilitates easy documentation of every aspect of clinic including clinical problem, interventions as well as clinical outcome. Using standardized terminologies aids in structuring of the data entry using a flexible expression that can be understood by all- novice and experts (Moen & Mæland Knudsen, 2013). The standardized terminologies aids in retrieval of coded data that have multiple attributes or have different levels of specificity. This helps in establishing a common link to the clinical knowledge base, thereby facilitating decision making process. Use of standardized language results into understanding the various continuum of care from different physicians, clinical settings, languages or health care systems. This is attributable to the fact that the various stakeholders involved can easily exchange and apply health information in an appropriate way (Moen & Mæland Knudsen, 2013).
In addition, standardized terminology is used to identify and monitor the outcomes of specific health needs or outcomes by pooling data from various resources. It supports the auditing of quality services and in benchmarking processes that support research. Consequently, it enables reporting of externally clinical and educational specified health statistics; which aids in the identification of individuals who needs proactive intervention (Moen & Mæland Knudsen, 2013).
The Importance of Standards in Information Technology and the Issues surrounding the standards
The main issue is keeping up the pace with the complex and dynamic standards. This makes most of the staff at the healthcare facility to remain unfamiliar with the emerging types of information being gathered or to understand where it fits in the health information standards realm. Most people still don’t understand the relationship between the standard code used and the major topics (Ajami & Arab-Chadegani, 2013).
Therefore, it is important to prioritize and emphasize on health informatics in order to set industry’s expectation. The Health Information Management staffs have a great responsibility to play the role as advocates for application of information technology and in educating their fellow colleagues. This is because standards contributes to longitudinal view of information technology and calls for the unified expectations on defining of data, its storage and transfer to process, identify and resolve service users needs. The ability to apply this information to drive successful decisions in business intelligence is an emerging responsibility for HIM staff (Moen & Mæland Knudsen, 2013).
The Importance of Standards in Information Technology References
Ajami, S., & Arab-Chadegani, R. (2013). Barriers to implement Electronic Health Records (EHRs). Materia Socio-Medica, 25(3), 213–215. http://doi.org/10.5455/msm.2013.25.213-215
Beaumont, R. (2000). Database and Database Management Systems. Retrieved from Fundamental Database Characteristics
Depart of Veterans Affairs. (2012). Health information management clinical coding program procedures. Retrieved from http://library.ahima.org/doc?oid=107104#.WO60IqL-vIU
Moen, A., & Mæland Knudsen, L. M. (2013). Nursing Informatics: Decades of Contribution to Health Informatics. Healthcare Informatics Research, 19(2), 86–92. http://doi.org/10.4258/hir.2013.19.2.86