Health Data Standards

• Standards are crucial for developing and implementing electronic health records (EHRs).
• Clinicians rely on these standards to access essential health data when and where needed, enhancing healthcare delivery.

Health Data Standards Classification

• Health data standards are categorized into Terminology, Content, Exchange, and Privacy/Security Standards.

Necessity of Data Standards in Healthcare

• Data standards in healthcare encompass specific methods and protocols.
• Data standards include terminologies, collection specifications, data exchange and storage.
• Data standards ensure the secure retrieval of information for healthcare applications.
• Healthcare applications include: medical records, medications, radiological images, plus payments, reimbursements, medical devices, monitoring systems, and administrative tasks.

Common Codes Include:

• ICD-10
• CPT
• HCPCS
• SNOMED-CT
• LOINC
• NDC
• CDT
• RXNORM

ICD-10 (International Classification of Diseases, 10th Revision)

• ICD-10 is a coding system created by WHO for documenting diagnoses, diseases, signs, symptoms, and other medical conditions.
• ICD-10 provides a uniform language for healthcare providers to share information globally.

ICD-10 Key Features:

• ICD-10 codes are alphanumeric and consist of three to seven characters.
  • A00: Cholera
  • J45.9: Asthma, unspecified
• ICD-10 facilitates billing and reimbursement.
• ICD-10 monitors disease prevalence and health trends.
• ICD-10 enables research and resource allocation.
• While some countries use it for diagnosis and health statistics, others, like the U.S., have adapted it for clinical use and added modifications
  • ICD-10-CM for diagnosis coding
  • ICD-10-PCS for procedure coding

CPT (Current Procedural Terminology)

• CPT is a set of codes, descriptions, and guidelines maintained by the AMA to standardize reporting of medical, surgical, and diagnostic procedures and services in the U.S.
• CPT ensures accurate communication among healthcare providers, patients, and payers concerning billing, documentation, and insurance reimbursement.

CPT Key Features:

• CPT codes consist of 5 numeric characters.
  • 99213 (office visit for an established patient).
• Modifiers can be added to indicate additional details.
  • "-25" for a significant, separately identifiable service
• CPT Category I codes cover standard procedures and services
  • surgeries
  • office visits
• CPT Category II codes cover performance measurement and tracking.
• CPT Category III codes cover emerging technologies and experimental procedures.
• CPT ensures uniformity in coding across the healthcare system.
• CPT facilitates claims processing and healthcare analytics.
• CPT supports medical research and quality improvement

HCPCS (Healthcare Common Procedure Coding System)

• HCPCS is a standardized coding system in the U.S. to identify medical procedures, supplies, products, and services.
• CMS established HCPCS to ensure consistency in billing and claims processing for Medicare, Medicaid, and other health insurance programs.

HCPCS Levels:

• Level I HCPCS codes are identical to CPT codes maintained by the AMA, covering medical services and procedures by healthcare professionals.
• Level II HCPCS codes are alphanumeric (e.g., A0425) and cover products, supplies, and services not included in CPT,
  • Durable Medical Equipment (DME): wheelchairs
  • Medications and Vaccines: injectable drugs
  • Ambulance Services: transportation services
  • Prosthetics and Orthotics

SNOMED CT (Systematized Nomenclature of Medicine)

• SNOMED CT is a comprehensive and standardized clinical healthcare terminology system used globally to record and share health information.
• SNOMED CT provides a universal language for describing diseases, clinical findings, procedures, body structures, and other healthcare concepts, ensuring consistency and interoperability across healthcare systems.
• SNOMED CT codes are numerical and consist of a minimum of six digits.
  • "n271737000" is the unique code for the SNOMED concept anemia (disorder).
• SNOMED CT includes clinical terms for diseases, symptoms, treatments, medical devices, anatomy, and laboratory findings.
• SNOMED CT helps document detailed and accurate patient data in EHRs.
• SNOMED is structured hierarchically, meaning terms are organized in categories that branch into subcategories.
  • "Respiratory disorder" is a parent term, with subcategories like "Asthma" or "Chronic obstructive pulmonary disease (COPD)."
• SNOMED CT is used internationally to support EHRs, clinical decision-making, and data exchange.
• SNOMED CT supports multilingual translations for global healthcare interoperability.
• SNOMED CT improves the accuracy and granularity of patient records in clinical documentation.
• SNOMED CT facilitates seamless data sharing across different healthcare systems and countries.
• SNOMED CT provides standardized data for epidemiology and healthcare trends in research and analytics.

LOINC (Logical Observation Identifiers Names and Codes)

• LOINC is a universal standard for identifying medical tests, measurements, and observations.
• The Regenstrief Institute develops and maintains LOINC, which is widely used in laboratories, healthcare organizations, and public health systems to ensure consistent communication of clinical and laboratory data.
• LOINC provides a standardized coding system for lab tests, clinical observations, and other measurements.
• LOINC ensures interoperability between different health systems, enabling the exchange of data across laboratories, clinics, hospitals, and public health agencies.
• Each LOINC term is assigned a unique code and corresponds to a specific test or observation.
• Codes typically have six parts: Component, Property, Timing, System, Scale, and Method.
  • 718-7 (Hemoglobin [Mass/volume] in Blood)
• LOINC Categories includes
  • Laboratory LOINC: lab tests like blood tests, urinalysis, microbiology, etc
  • Clinical LOINC: clinical measurements like vital signs, imaging, and survey instruments.
• LOINC standardizes lab results across different labs and systems.
• LOINC facilitates electronic exchange of test results in EHRs.
• LOINC supports public health initiatives, research, and data reporting.
• LOINC is used internationally and integrates with other standards like HL7 and SNOMED CT for seamless health data exchange.

NDC (National Drug Code)

• The National Drug Code (NDC) is a unique 10- or 11-digit, 3- segment number used in the U.S. to identify medications and serve as a universal product identifier for human drugs.
• The Labeler Code identifies the company that manufactures, repackages, or distributes the drug.
• The Product Code identifies the specific strength, dosage form, and formulation of the drug.
• The Package Code identifies the package size and type.
• The NDC is typically used for inventory management, insurance claims, and ensuring traceability in the pharmaceutical supply chain.
• The FDA assigns the NDC.

CDT (Current Dental Terminology)

• CDT is a standardized set of codes maintained by the ADA for documenting and billing dental procedures and services.
• CDT ensures consistency and accuracy in dental recordkeeping and facilitates communication between dentists, insurance providers, and patients.
• CDT provides a universal language for documenting dental services.
• CDT supports dental claims submission for insurance reimbursement.
• CDT ensures standardization across dental practices and systems.
• CDT codes are 5-character alphanumeric codes, starting with "D" followed by four numbers.
  • D1110 Prophylaxis (teeth cleaning) for an adult
• Dentists use CDT to document procedures in patient records.
• CDT facilitates claims processing with dental insurance providers.
• CDT supports research, reporting, and data analysis in the dental field.
  • D0210
  • D2330

RxNorm

• RxNorm is a standardized nomenclature for medications developed by the NLM.
• RxNorm provides normalized names and unique identifiers for drugs, enabling consistent representation and communication of medication data across healthcare systems, EHRs, and pharmacy management systems.
  • RXCUI 198013
  • RXCUI: 5640
• RxNorm ensures interoperability between different healthcare systems by standardizing medication names and formats.
• RxNorm facilitates the exchange of drug-related information, such as prescriptions, allergies, and adverse reactions.
• It includes clinical drug names a specific dose form like "Aspirin 81 mg oral tablet".
• It includes ingredients, strengths, and dose forms.
• It includes brand and generic names.
• It links to other drug vocabularies and coding systems (e.g., NDC, SNOMED CT).
• RxNorm is designed to work with other coding systems such as NDC, SNOMED CT, LOINC, and ICD-10 to support healthcare data exchange.
• RxNorm Use Cases is electronic prescribing, decision support and interoperability.

International Organization for Standardization (ISO)

• ISO is an independent, non-governmental international organization that develops and publishes standards for a wide range of industries.
• ISO standards help ensure quality, safety, efficiency, and interoperability across various sectors and countries.

ANSI (American National Standards Institute)

• ANSI oversees the development and promotion of standards in the United States.
• ANSI coordinates the creation of voluntary consensus standards across a variety of industries, including technology, safety, manufacturing, and more.
• ANSI ensures that the standards created are balanced, transparent, and reflect the interests of all stakeholders.
• ANSI is the U.S representative to ISO and is responsible for bringing forward U.S standards to that organization.

HIPAA (Health Insurance Portability and Accountability Act of 1996)

• HIPAA required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.