Domain I - Chapter 5

Clinical Document Architecture (CDA)

1. Provides an exchange model for clinical documents (such as discharge summaries and progress notes) 2. "A document markup standard that specifies the structure and semantics of 'clinical documents' for the purpose of exchange between healthcare providers and patients"

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

A US clinical modification of WHO ICD-10 maintained by the National Center for Health Statistics (NCHS), and is a morbidity classification system that classifies diagnosis and other reasons for healthcare encounters

International Classification on Functioning, Disability, and Health (ICF)

A classification developed by the WHO of health and health-related domains that describes body functions and structures, activities, and participation

Clinical classification

A clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings; provides for the proper use of clinical words as names or symbols; and facilitates mapping of standardized terms to broader classifications for administrative, regulatory, oversight, and fiscal requirements

Morphology

A code in the ICD-O-3 that describes the characteristics of a tumor itself, including cell type and biological activity

Topography

A code in the ICD-O-3 that describes the site of origin of the neoplasm

Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

A comprehensive, multihierarchical, concept-oriented clinical terminology owned, maintained, and distributed by the International Health Terminology Standards Development Organization (IHTSDO)

Clinical vocabulary

A formally recognized list of preferred medical terms

Mapping

A function that allows for the reuse of data captured for one purpose to be used for other purpose

Unified Medical Language System (UMLS)

A government-funded project from the NLM that has been in development since 1986, with the purpose to facilitate the development of computer systems that behave as if they "understand" the meaning of the language of biomedicine and health, and provides data for system developers as well as search and report functions for less technical users

International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)

A procedure coding system developed under contract by CMS as a replacement of the ICD-10-CM procedure coding system for hospital reporting of inpatient procedures

MEDCIN

A proprietary clinical terminology owned and maintained by Medicomp Systems

Nomenclature

A recognized system of terms used in a science or an art that follows preestablished naming conventions

Current Dental Terminology (CDT)

A reference manual maintained and updated annually by the American Dental Association (ADA)

Systemized Nomenclature of Medicine Reference Terminology (SNOMED RT)

A reference terminology that includes an elementary mapping to ICD-9-CM

Reference terminology

A set of concepts and relationships that provide a common consultation point for comparison and aggregation of data about the entire healthcare process, recorded by multiple individuals, systems, and institutions

Clinical terminology

A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient details to support clinical care, decision support, outcomes research, and quality improvement

Terminology

A set of terms representing a system of concepts of a particular subject or field

RxNorm

A standardized nomenclature for clinical drugs that provides information a drug's ingredients, strengths, and form in which it is to be administered or used, and is produced by the National Library of Medicine (NLM)

National Drug Codes (NDCs) directory

A universal product identifier for human drugs that identifies the labeler or vendor, product, and trade package size

Continuity of Care Document (CCD)

An implementation guide for sharing CCR patient summary data using the CDA

Transition of care (ToC) initiative

An initiative that works towards interoperability, and one of the projects of the Standards and Interoperability (S&I) Framework

International Health Terminology Standards Development Organization (IHTSDO)

An international nonprofit organization based in Denmark that owns, maintains, and distributes SNOMED CT

International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

Classification is used for coding diagnoses of neoplasms in tumor and cancer registries and in pathology laboratories

Interface terminology

Concerned with facilitating clinical documentation within the standardized structure needed for an EHR

Clinical information model (CIM)

Consists of unambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions

International Classification of Diseases, Eleventh Revision (ICD-11)

Designed to include linkages to standardized healthcare terminologies to facilities processing and use of the data for a variety of purposes such as research

International Classification of Diseases (ICD)

Facilitates the storage and retrieval of diagnostic information and serves as the basis of compiling mortality and morbidity statistics reported by WHO members

Semantic interoperability

In which the information being transmitted is understood

Patient medical record information (PMRI)

Information in which SNOMED CT is part of a core set of technology

Current Procedural Terminology (CPT)

Published by the American Medical Association and provides a uniform language that accurately describes medical, surgical, and diagnostic services, thereby services as an effective means for reliable nationwide communication among physicians, patients, and third parties

Functional interoperability

Refers to sending messages between computer with a shared understanding of the structure and format of the message

Basic interoperability

Relates to the ability to successfully transmit and receive data from one computer to another

Medical Subject Headings Database (MeSH)

The NLM's controlled vocabulary thesaurus, which consists of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity

Interoperability

The capacity of different information systems and software applications to communicate and exchange data

Logical Observation Identifiers Names and Codes (LOINC)

The exchange standard for laboratory results; a clinical terminology that provides a common language for clinical laboratory observations

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

The handbook used by healthcare professionals as a guide to diagnose mental disorders and was first published by the American Psychiatric Association (APA) in 1952

Lexicon

The listings of words or expressions in a language (terminology) and information about the language such as definitions, related principles, and description of structure (grammatical)

Concept

The most granular unit within a terminology

National Library of Medicine (NLM)

The world's largest medical library that collects materials in all aspects of biomedicine and healthcare, as well as works on biomedical aspects of technology, the humanities, and the physical, life, and social sciences

Clinical Care Classification (CCC)

Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings

Healthcare Common Procedure Coding System (HCPCS)

Used to report services and supplies primarily for reimbursement purposes in the outpatient or ambulatory services