HIHIM407 Final;

Nomenclature

(Nomen= to name + calare = to call) A naming convention or systematic listing of names assigned according to convention. Synonymous with Vocabulary. A system of preferred terminology for naming disease processes. Is a naming convention or systematic listing of name that have been assigned according to pre-established rule. a.A classified system of technical or scientific names b.A defined system for naming c.Synonymous with vocabulary SNOMED (systematized nomenclature of medicine = both a vocabulary and nomenclature) Some overlap between term nomenclature and vocabulary *Example: SNOMED-CT, UMDNS, SNOP

GEMs

=General Equivalence Mappings A comprehensive translation dictionary to help convert ICD9-CM-to ICD-10-CM or PCS Created by CMS & CDC. Can be used to convert large applications with a high degree of complexity and still preserve the essential logic of the application. *GEMs are not a simple one-to-one crosswalk. The GEMs are complete for all the mapping possibilities as well as when there are new concepts.

Reference Terminology

A concept-based, controlled medical terminology •Identifies relationships between concepts •Relationships can be hierarchical

Vocabulary

A list or collection of clinical words or phrases with their meanings means all the terms that are recognized for communication within a domain, it is a collection of words or phrases. A set of words used by an individual or group within a particular subject field. Example: ICD-9, SNODENT

Terminology

A set of terms representing the system of concepts of a particular subject or field. (CONCEPTs within the area of interests). Example: CPT-> The Common Procedural Terminology In contrast to a vocabulary, a terminology includes a prescribed set of terms authorized for specific use.

Basic Interoperability

Allows a message from one computer to be received by another. It does not require the receiving computer to be able to interpret the data viewed as (technical connectivity) Example: putting letter in and envelope and mailing it( it doesn't matter what is in the envelope

Administrative terminologies

Are classification and coding systems that are primary designed to support the administrative, financial, and regulatory functions associated with patient care. Primary communication tools for those providing the services and those paying for those services.

Transverse Lie or Shoulder Position

Bob position horizontally across the uterus. Rotate may help. Kimkbaby#2

Unstructured data entry

Clinicians can use free-text data to enter info directly online or dictate their notes directly or voice-activated *Example: type free text to indicate the Reason for Request when ordering a consultation.

Functional Interoperability

Defines the format of messages. This ensure Messages between computers can be interpreted at the level of the data fields so that the Data can pass from a structured field in one system to a comparably structured field in another. Neither system understands the meaning of the data in the field. Example: similar to the email in that the format agreed on with TO/From/Subject/Message. Technical connectivity is achieved and most follow a standard format. But the system is not trying to understand the meaning of the message

Clinical terminologies

Designed to facilitate clinical documentation in the EHR and data collection at the point of care to record. -Designed to be embedded in the EHR -Each term is represented as a concept and has a code -These codes are used to transmit health data cross systems for analysis, aggregation and use at the point of care Example: SNOMED-CT

Structured data entry

Entry allows to draw from standard phrases or pick lists and pull-down menus to help guide the entry and ensure that complete information is included. *Example: pick list appear on the consult order to prompt the use of standardized data to name and direct the order to the appropriate services and specialty. *Example: other structured data needed for the consultation order include selections to indicate urgency, inpatient/outpatient services and location where consultation will take place.

Occiput Posterior Position

Face up. Problem: baby can't extend head out from under the pubic bone. More difficult to deliver. Some baby may turn on their own or need help to rotate.

HL7

Health Level 7- The first clinical message standard. Relationship: LOINC works with partner standards to make up a message that needs to communicate the laboratory test results from the laboratory systems to a diagnostic test results application. HL7 exchange standards as supplying the wagon to carry the message and the LOINC code to be used to describe the clinical observation or test result riding in the wagon.

Controlled Reference terminology

Is a coded vocabulary of medical concepts and expressions used in health care. It is concept-based and allows for the complex organization and aggregation of clinical information. The terms to manage the content to ensure that it structurally sound, biomedically accurate and consistent with current practice. Example: ICD-9, SNODENT

LOINC

Logical Observation Identifiers Names and Codes- Is a universal code system used for identifying laboratory and clinical observations. LOINC uses standardized terms including clinical terms such as blood pressure and laboratory test names, and has standardized terms for all kinds of observations and measurements that can be used when health information is exchange.

Controlled vocabulary

Means that the terms within the vocabulary are carefully selected for their inclusion; terms outside the boundary are not included. Example: ICD-9-CM: used to classify morbidity and mortality data. (includes & excludes) SNODENT- Systematized Nomenclature of Dentistry. Example: Yellow Pages, when you look up doctors, you will be directed to look up (physician and surgeons) using the preferred terminology not vernacular. Two rules are followed: 1. if the same name use to mean the same concepts, then its name explicitly qualified to resolve the ambiguity. 2. Multiple terms use to mean the same thing, one of the term is identify as a preferred term, and the other are synonyms. Oral cancer or mouth tumor will be map as "MOUTH NEOPLASMA", white spots or tooth decay will be map to " DENTAL CARIES

Occiput Anterior position

Most common birth position. Normal. Face down, turned slightly to the side, the smallest part of baby's head leads the way through the birth canal

Semantic Interoperability

Provides common interpretability, that is, information within the data fields can be used intelligently. Allows information to be understood by shared systems. This level of interoperability is dependent on the degree of agreement of data terminology and its quality. Example: on Methodist University hospital robots were used in the pharmacy, because they use semantic interoperability, various fields mean same thing across systems. This enables CPOE information to be understood by the robots

RxNorm

Provides normalized names and unique identifiers to be applied to both brand name and generic drugs. Support the interoperation between drug terminologies and pharmacy knowledge base systems. Created and updated by NLM- The national Library of Medicine. *RxNorm standard is required in the e-prescribing function in ambulatory EHRs.

Granularity

Refers to the degree of specificity and refinement of a term. Different users are likely to require different levels of granularity. Terminologies that include multiple granularities of the same content can support many more users than those with a single level of granularity. Example: ICD-9-CM vs. ICD-10-CM (code sets #) *This shows granularity greatly assists in identifying medical conditions and procedures with high precision. Example: Paint: Put two specific color together in one bucket, but it is almost impossible to spate them back into the original colors they once were.

RELMA

Regenstrief LOINC Mapping Assistant: Its the tool used to view and search the LOINC database. Purpose: of the database is to facilitate the exchange or results for clinical care, outcomes management, and research.

SNOP

Systematized Nomenclature of Pathology Purpose: storing medical information, such as: routine orderliness, stats reports,case finding for teaching.

ICD-0

The ICD for Oncology: is another system derived from ICD. It is used to classify neoplasm according to their site. Codes are based on the malignant neoplasm codes in ICD-10. The oncology classification is oriented on axes. There is a topography axis and a morphologic axis.

UMDNS

The Universal Medical Device Nomenclature System. Is a proprietary, standardized, and controlled international nomenclature and coding system for medical devices. Purpose: Facilitate identifying, processing, filling, storing, retrieving, transferring, and communicating data about medical devices, clinical laboratory equipment, etc.

Interoperability

The ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and network in various settings, and exchange data such that clinical or operational purpose the meaning of the data are preserved and unaltered.

Data mapping

The process of creating data elements mappings between semantic and representational terms residing in two distinct data models. Data mapping is used as a first step in data integration which involves combining terms residing in different sources and to provide users with a unified view of these data.

Classification

The scheme of grouping similar things in a logical way on the basis of common characteristics. It is a system that is clinically descriptive and arranges or organizes like or related entities. Items are grouped according to type or class within an organized system purpose of classification is statistical analysis and reporting . *Example: Dewey decimal system for libraries or animals- genus and species, (ICD-9-CM vs. ICD-10) -> (17,000 vs. 155,000 codes)- grouped, but granularity differs. Terminology and Nomenclatures are more granular than classification.

UMLS

Unified Medical Language System To facilitate the development of computer systems that behave as if they "understand" the meaning of the language of biomedicine and health. Created by NLM- the U.S. National Library of Medicine. It connects scores of vocabs, classifications, and other source by concept, allowing users to map data from one terminology to another.

Specificity

Used in classification systems vary in their level of detail; some offer very general groupings, whereas others allow more detailed groupings and subgroupings, enabling the user to capture greater degree of specificity ( a level of detail).

Clinical interface terminology

a set of clinically relevant terms mapped to the industry standard administrative and clinical code sets.