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Understanding Terms and Definitions
By Shahid N. Shah MS
As per the HHS rules, vocabulary standards are standardized nomenclatures and e-code sets used to describe clinical problems and procedures, medications, and allergies for eMRs. Some commons terms and definitions are listed below:
Terms and Definitions
- ASTM’s CCR – for most of your basic patient summary exchange needs the CCR will meet your needs. If you’re moving from low or no interoperability today to some interoperable capabilities then CCR is your best starting place.
- International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9- CM) or SNOMED CT® should populate a problem list. If you’re not familiar with both standards and are unsure where to start, go with ICD-9 for problem lists. SNOMED is not commonly supported in the broad EMR industry but ICD-9 support is quite common so start there.
- Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2 (R2) Level 2 CCD – for more advanced patient summary exchange needs the HL7 CDA is recommended. If you’re already supporting CCR exchange and it’s not meeting your needs then HL7 CDA is the next logical place to go.
- For patient summary exchanges, HHS expect the following fields to be populated: problem list; medication list; medication allergy list; procedures; vital signs; units of measure; lab orders and results; and, where appropriate, discharge summary.
- ICD-9-CM [ACD-10] or American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT–4) to populate information related to procedures. Both of these standards are support broadly by most existing vendors so going with either or both is good.
- For medication lists, HHS requires the use of codes from a drug vocabulary the National Library of Medicine has identified as an RxNorm drug data source provider with a complete data set integrated within RxNorm.
- For lab results, HHS requires the use of LOINC® to populate information in a patient summary record related to lab orders and results when LOINC® codes have been received from a laboratory and are retained and subsequently available in your EMR. HHS states that in instances where LOINC® codes have not been received from a laboratory, the use of any local or proprietary code is permitted. HHS does not require these local or proprietary codes to be converted to LOINC® codes in order to populate a patient summary record.
- For the purposes of electronic prescribing, your vendor must be capable of using NCPDP SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. With respect to a vocabulary standard, your vendor must use codes from a drug vocabulary currently integrated into the NLM’s RxNorm. For the purposes of performing a drug formulary check, your vendor must be capable of using NCPDP Formulary & Benefits Standard 1.0 adopted by HHS (73 FR 18918).
- There are standards required for insurance data like eligibility checking and submissions of claims. ASC X12N and NCPDP standards (Versions 4010/4010A and 5010 and Versions 5.1 and D.0, respectively) should be used for these transactions. It’s important to realize that Version 4010 is being phased out in favor of Version 5010 so your vendors need to support both at this time and must be able to move exclusively to Version 5010 in the future.
- For the purposes of electronically submitting calculated quality measures required by CMS or by States, your vendor must be capable of using the CMS PQRI 2008 Registry XML Specification. Going forward, HL7 Quality Reporting Document Architecture (QRDA) Implementation Guide based on HL7 CDA Release 2 may be allowed but for now focus on the CMS PQRI requirements until HHS provides more guidance in the future.
- For the purposes of submitting lab results to public health agencies, your vendor must be capable of using HL7 2.5.1.
- For the purposes of electronically submitting information to public health agencies for surveillance and reporting, your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard. At this time HHS not required adverse event reporting nor have they adopted a specific vocabulary standard for submitting information to public health agencies for surveillance and reporting.
- For the purposes of electronically submitting information to immunization registries your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard and the CDC maintained HL7 standard code set CVX -Vaccines Administered18 as the vocabulary standard.
Assessment
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Filed under: CMP Program, Information Technology, Practice Management | Tagged: ASTM’s CCR, CC, CCR, CMS, CMS PQRI 2008 Registry XML Specification, EHRs, EMRs, health information technology, Health Level Seven, HHS, HL7 Quality Reporting Document Architecture (QRDA) Implementation Guide based on HL7 CDA Release 2, ICD-9-CM, LOINC®, NCPDP SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6., NCPDP standards, Shahid N. Shah |
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Most Doctors Using at Least Partial eMRs – Acccording to the CDC
Adoption of health information technology is growing among office-based physicians, according to preliminary results of a survey released by the Centers for Disease Control and Prevention [CDC].
More than half of physicians reported using at least a partial electronic health-record system in their practices, according to 2010 estimates from the National Ambulatory Medical Care Survey, conducted by the CDC’s National Center for Health Statistics. That figure is up slightly from 48.3% of physicians in 2009.
Nearly a quarter of physicians surveyed said they had an EMR in place that met criteria for a basic system, defined as having capabilities for viewing imaging results, medication lists, lab results and other features. And about 10% said they have a fully functional system in place.
Rates of adoption, however, varied widely from state to state, researchers found. More than 80% of office-based physicians in Minnesota reported having at least a partial EMR in place in 2010, but the rate was less than 40% in Kentucky and Louisiana.
Source: Maureen McKinney, Health IT Strategist [12/10/10]
PS: IMHO however, a partial eMR is a terminology misnomer. Rather, it is a digital record; not a true interoperable – and MU qualified – eMR.
Dr. David Edward Marcinko MBA
[Health Dictionary Series]
http://www.springerpub.com/Search/marcinko
[Editor-in-Chief]
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About the 5010 Standards
Shahid – excellent post. And, in addition, medical practices face two significant deadlines that require planning and testing in 2011.
The first deadline of January 1, 2012, is for the adoption of a new standard — the 5010 standard —for electronic claims transactions.
The second deadline is the long-awaited (or long-dreaded) deadline for moving from the ICD-9 to the ICD-10 code set. This deadline is slated for October 1, 2013
http://www.physicianspractice.com/pearls/content/article/1462168/1720195?GUID=E5D1C438-A423-4146-A0D3-9E314F5871B2&rememberme=1
http://www.physicianspractice.com/tools/content/article/1462168/1720165?GUID=E5D1C438-A423-4146-A0D3-9E314F5871B2&rememberme=1
Hope R. Hetico RN MHA
http://www.BusinessofMedicalPractice.com
[Managing Editor]
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CMS Delays 5010 Enforcement, Again
The CMS will not begin enforcing the mandated move to Version 5010 transaction standards for an additional three months, until after June 30th. The deadline for the switch to the 5010 standards was January 1st. In November, the CMS announced that although it was not changing the actual deadline for complying with the standards, it would not initiate enforcement action until March 31st.
Yet, on Thursday, the CMS’ Office of E-Health Standards and Services said no action will be taken against noncompliant medical practices, hospitals, and other healthcare entities through June 30th. In February, the MGMA-ACMPE (formerly the Medical Group Management Association) requested more time, citing complaints from physicians that the conversion was resulting in “significant delays” in claims payment.
Source: Andis Robeznieks, Modern Healthcare [3/15/12]
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