Record smoking status for patients
Assignment: Answer Real world cases 5.1 and 5.2 questions; at least one page for each real world case; cite textbook. Please see chapter readings from textbook below
Real-World Case 5.1
The 2015 Edition EHR technology certification criteria state the following:
Smoking status: Enable a user to electronically record, change, and access the smoking status of a patient in accordance with the standard specified.
· 45 CFR 170.315(a)(11). Coded to one of the following SNOMED CT codes:
· Current everyday smoker. 449868002
· Current some day smoker. 428041000124106
· Former smoker. 8517006
· Never smoker. 266919005
· Smoker, current status unknown. 77176002
· Unknown if ever smoked. 266927001
· Heavy tobacco smoker. 428071000124103
· Light tobacco smoker. 428061000124105
Objective: Record smoking status for patients 13 years or older.
Measure: More than 85 percent of all unique patients 13 years old or older seen by the eligible professional or admitted to the eligible hospital’s or critical care hospital’s inpatient or emergency department during the EHR reporting period have smoking status records as structured data.
A quick reference for meeting the smoking status promoting interoperability requirement is included in the American Academy of Family Physicians (AAFP) Tobacco and Nicotine Cessation Toolkit. The AAFP supports the incorporation of tobacco cessation into EHR templates (AAFP 2015). The quick reference provides guidance on what should be included in a tobacco cessation EHR template.
Real World Case 5.1
1. Why would SNOMED CT be used to record the smoking status of a patient on an EHR template?
2. Why was ICD-10-CM not chosen as the system to capture smoking status?
3. Review the SNOMED CT codes. Which ones have a namespace identifier and an extension? What part of the identifier is the namespace and what part is the extension?
Real-World Case 5.2
Opioid use is a major concern for healthcare professionals and organizations worldwide. Even governmental agencies are becoming involved. For example, the National Institutes of Health launched the Helping to End Addiction Long-term as a way to speed scientific solutions to curtail the national opioid public health crisis. The accurate identification of opioid use disorder is important to the success of the research that will take place. DSM-5, ICD-10-CM, SNOMED CT, and in the future ICD-11-MMS are all possible ways to identify cases for research.
Real World Case 5.2
1. Why would DSM-5, ICD-10-CM, SNOMED CT, and ICD-11-MMS be used to record opioid use disorder?
2. If you were helping with a research study on opioid use disorder and asked to identify what should be included from SNOMED CT, ICD-10-CM, and ICD-11-MMS for opioid use disorder, what would your report say?
Websites may be used to look up opioid use disorder:
SNOMED CT: https://browser.ihtsdotools.org/
ICD-10-CM: https://www.icd10data.com/
ICD-11-MMS: https://icd.who.int/browse11/l-m/en
3. Considering the same research study, what would you point out as changes in the classification for opioid use disorder between ICD-10-CM and ICD-11-MMS?
HITT 1301 CHAPTER 5
Health Information Management Technology,
An Applied Approach
Nanette Sayles, Leslie Gordon
Copyright ©2020 by the American Health Information Management Association. All rights reserved.
Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying,
recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue,
21st Floor, Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint).
ISBN: 978-1-58426-720-1
AHIMA Product No.: AB103118
Clinical Terminologies, Classifications, and Code Systems
Health information management (HIM) professionals play a crucial role in capturing and organizing clinical data. With the adoption of electronic health records (EHRs), organizing clinical data may involve several labels. For example, the Office of the National Coordinator for Health Information Technology (ONC) uses vocabulary (a list of collection of clinical words or phrases with their meanings), terminology, or code set to describe standards to support interoperability (ONC 2018a). Vocabulary is a list or collection of clinical words or phrases with their meanings. Standards organizations may also use the label nomenclature (a recognized system of terms that follows pre-established naming conventions), classification (a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings), or code system (an accumulation of terms and codes for exchanging or storing information). See table 5.1 for general definitions of each label. Nomenclature is a recognized system of terms that follows pre-established naming conventions. Classification is a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings and facilitates mapping standardized terms to broader classifications or administrative, regulatory, oversight, and fiscal requirements. A code is an identifier of data. A code set is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic or procedure codes, and includes the descriptors of the codes. A code system is the accumulation of terms and codes for the exchange or storing of information.
This chapter discusses clinical terminologies, classifications, and code systems used in the healthcare industry to encode clinical data in a standardized manner. Clinical terminologies are sets of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement. They contain terms and codes just as a code system does. As this chapter will explain, certain clinical terminologies are more appropriate for the collection of clinical data at a granular level (data consisting of small components or details at the lowest level) such as SNOMED CT. Others are best utilized for the aggregation of clinical data for secondary data purposes; for example, ICD-10-CM.
In addition, terminologies, classifications, and code systems are a key type of data managed by the data governance function. Understanding their purpose and use is necessary to succeed in managing the usability of the data employed by the healthcare organization.
History and Importance of Clinical Terminologies, Classifications, and Code Systems
Clinical terminologies, classifications, and code systems exist to name and arrange medical content so it can be used for patient care, measuring patient outcomes, research, and administrative activities such as reimbursement. What started as a way to identify causes of death for statistical purposes, expanded to reporting diagnoses and procedures on claims for reimbursement. Today, the electronic health record (EHR) can capture the detail of diagnostic studies, history and physical examinations, visit notes, ancillary department information, nursing notes, vital signs, outcome measures, and any other clinically relevant observations about the patient. Figure 5.1 illustrates a comparison of claims data and EHR data and the vast difference in clinical content.
Figure 5.1 What lies beneath?
Source: Shulman and Stepro 2015. Used with permission.
Investigating the reasons for collecting data illustrates the importance of clinical terminologies, classifications, and code systems. If data granularity, or detail, is the goal, then clinical terminologies are the best option. On the other hand, if the objective is aggregate data, then classifications are the better choice. Aggregate data is data extracted from individual health records and may be combined to form deidentified information about groups of patients that can be compared and analyzed. With regards to code systems, some are for the collection of clinical data at a granular level while others are for aggregation. Table 5.2 lists examples of data uses and their data requirements. As the table shows, granular data is needed when the details are key to use whereas aggregate data suits when the combination of data provides information about related entities that is sufficient.
Additionally, primary and secondary data uses are relevant to understanding clinical terminologies, classifications, and code systems. A terminology that allows for the collection of clinical data at a granular level is needed for primary data use such as for clinical decision support. One that aggregates the data will work for secondary data use. An example of secondary data use is the identification of diagnoses and procedures for the purpose of billing and payment. For more information on primary and secondary data, see chapter 7, Secondary Data Sources.
The determination of which clinical terminologies, classifications, and code systems are used as the standard is primarily driven by regulation. Standards are critical for creating an interoperable health information technology (IT) environment (ONC n.d.). An interoperable health IT environment is one in which seamless health information exchange is possible across different EHR systems and the information is understood and shared with those in need of it at the time it is needed. Clinical terminologies, classifications, and code system standards are one of the ONC’s interoperability building blocks. They support system interoperability by providing the mutual understanding of the meaning of data exchanged between information systems.
Congress creates legislation authorizing the establishment of standards through regulatory agencies. For example, the Electronic Health Record Standards and Certification Criteria Rule defines the standards that must be used for EHR technology to be certified by the authorized Certification Bodies. Included in this rule are the content standards for representing electronic health information such as SNOMED CT for problems and RxNorm for clinical drugs, which will be discussed later in this chapter.
Clinical Terminologies
A clinical terminology is a set of standardized terms and codes for the healthcare industry for use in encoding clinical data. Examples of clinical terminologies include SNOMED CT, Current Procedural Terminology, and various nursing terminologies. Clinical terminologies form the basis of coded data and provide the data structure required for semantic interoperability and health information exchange. Semantic interoperability is the mutual understanding of the meaning of data exchanged between information systems. Health information exchange is when health information is electronically traded between providers and others with the same level of interoperability. Clinical terminologies may also be reference terminologies. A reference terminology in the health information technology (HIT) domain is “a terminology designed to provide common semantics for diverse implementations” (CIMI 2013).
SNOMED Clinical Terms
SNOMED Clinical Terms, or SNOMED CT, is the most comprehensive, multilingual clinical healthcare terminology in the world (SNOMED International 2017a). There is no book of SNOMED CT codes and no coding professional assigns a SNOMED CT identifier. The terminology instead is implemented in software applications where healthcare providers record clinical information using identifiers that refer to concepts that are formally defined as part of the terminology during the process of care (SNOMED International 2017b). It allows for the collection of clinical data at a granular level. For example, at the point of care a physician using an EHR uses a drop-down list to view the clinical terms relevant to their practice and the patient’s problem. While not seen by the physician, the clinical terms have SNOMED CT identifiers attached to them. By selecting the clinical term, the identifier is captured and thereby provides the primary source of information about the patient.
SNOMED CT Purpose and Use
SNOMED CT’s overall purpose is to standardize clinical phrases, making it easier to produce accurate electronic health information. Doing so enables automatic interpretation and sharing of clinical information. Semantic interoperability is also possible. (Semantic interoperability is discussed in more detail in chapter 11, Health Information Systems.)
With the consistent, reliable, and comprehensive capture of clinical phrases with SNOMED CT, its uses and benefits are many.
With the SNOMED CT encoded data sent securely during the transfer of care to other providers or to patients, the barriers to the electronic exchange are reduced resulting in improved quality of the information. SNOMED CT coded data combined with other encoded data, such as medication and lab results, have a number of uses including clinical decision support, clinical quality measures, and registries (Helwig 2013). For more information on registries, see chapter 7, Secondary Data Sources. Quality measures are discussed in chapter 18, Performance Improvement.
SNOMED CT is also one of several standards chosen for the entry of structured data in certified EHR systems (ONC 2015). This includes patient problems, encounter diagnosis, procedures, family health history, and smoking status. The National Library of Medicine (NLM) produces the Clinical Observations Recording and Encoding (CORE) problem list subset of SNOMED CT. This subset includes SNOMED CT concepts commonly used for encoding clinical information at a summary level, such as the problem list.
SNOMED CT Content and Structure
SNOMED CT is made up of three main components—concepts, descriptions, and relationships. Each component is assigned a unique, numeric, and machine-readable SNOMED CT identifier (SCTID). The SCTID identifier is a unique integer that includes an item identifier, a partition identifier, and a check-digit. It may also include a namespace identifier when the component originates in an extension. SNOMED International issues a namespace identifier to an organization with the responsibility of creating, distributing, and maintaining a SNOMED CT extension. An extension occurs when the SNOMED CT International release does not contain content needed at the national, local, or organizational level.
The SCTID is nonsemantic; therefore, no meaning is inferable from the numerical value of the identifier or from the sequence of digits. Figure 5.2 provides an example of the SCTID for the concept nosocomial pneumonia found in the international edition and Figure 5.3 shows the SCTID for disorder of right lower extremity found in the US national extension. The partition identifier of 00 and 10 indicates the nature of the component identified is a concept.
Figure 5.2 SCTID for the concept nosocomial pneumonia SNOMED CT International Edition 20180731 release
Source: © AHIMA.
Figure 5.3 SCTID for the concept disorder of right lower extremity US national extension 20180901 release
Source: © AHIMA.
Concepts are a unique unit of knowledge or thought created by a unique combination of characteristics. SNOMED CT defines a concept as “a clinical idea to which a unique concept identifier has been assigned” (SNOMED International 2018). Examples of clinical concepts are diagnoses (for example, coronary arteriosclerosis) and procedures (for example, coronary artery bypass grafting). A concept has only a single meaning even though more than one term may be associated with a concept. The SNOMED CT concept definition is a set of one or more axioms, or true statements, that serve as a starting point for further reasoning and arguments (SNOMED International 2017a). The axioms may either partially or sufficiently specify the SNOMED CT concept’s meaning. When the defining characteristics are enough to define the concept in the context of its hierarchy, it is sufficiently defined. In the case of a concept that does not have the required characteristics to distinguish it from similar concepts, it is partially defined; that is, it is a primitive concept. The concept nosocomial pneumonia is sufficiently defined by the following characteristics:
· Nosocomial pneumonia is a healthcare-associated infectious disease
· Nosocomial pneumonia is an infective pneumonia
· Nosocomial pneumonia has the following attributes:
∘ Pathological process: infectious process
∘ Associated morphology: inflammation and consolidation
∘ Finding site: lung structure
An example of a primitive concept is unsolved lobar pneumonia. Its characteristics are:
· Unsolved lobar pneumonia is a lobar pneumonia
· Unsolved lobar pneumonia is an unsolved pneumonia
· Unsolved lobar pneumonia has the following attributes:
∘ Associated morphology: inflammation and consolidation
∘ Finding site: structure of lobe of lung
Descriptions are human-readable representations of concepts. A SNOMED CT concept may have multiple descriptions. Each is designated a description type: a fully specified name or a synonym. In SNOMED CT the fully specified name (FSN) is the unique text assigned to a concept that completely describes it, and the synonym is an alternative way to describe the meaning of the concept in a specific language or dialect. More than one synonym may exist. One of the synonyms is noted as the preferred term and is the description or name assigned to a concept that is used most commonly in a clinical record or in literature for a specific language or dialect. In the example of transient cerebral ischemia, the fully specified name is transient ischemic attack (disorder). The term enclosed in parentheses at the end is called the semantic tag. It allows differentiation among concept domains such as ulcer (disorder) from ulcer (morphologic abnormality). Examples of synonyms for transient ischemic attack (disorder) are transient cerebral ischemia, temporary cerebral vascular dysfunction, and transient ischemic attack. In the case of transient ischemic attack (disorder) the preferred term is transient cerebral ischemia for the English language, US dialect.
Relationships are a type of connection between two concepts; for example, a source concept and a destination concept. These relationships between SNOMED CT concepts define them. Structured according to logic-based representation of meanings, they form the poly-hierarchical structure of SNOMED CT. At the top of the hierarchy is the root concept. Descended from the root concept are specific domain hierarchies. For example, coronary arteriosclerosis belongs to the clinical finding domain hierarchy while coronary artery bypass grafting belongs to the procedure domain hierarchy. Figure 5.4 shows how the concept arthritis of the knee belongs only to the clinical finding domain hierarchy.
Figure 5.4 SNOMED CT design
Source: SNOMED International 2017b. Used with permission.
Values of a range of relevant attributes make up the defining characteristics of a concept (SNOMED International 2018). Defining characteristics include the “is a” relationship and defining attribute relationships. The “is a” relationship type indicates the source concept is a subtype of the destination concept. For example, figure 5.4 shows the “is a” relationship type indicating arthritis of knee is a subtype of arthropathy of knee joint. The defining attribute relationship is not found in all domain hierarchies. For example, the defining attribute relationships for rheumatoid arthritis of hand joint, associated morphology and finding site, are used to associate the source concept rheumatoid arthritis of hand joint to the target concepts of inflammation (associated morphology) and hand joint structure (finding site).
Current Procedural Terminology
The American Medical Association (AMA) owns the copyrights to Current Procedural Terminology (CPT). According to the AMA, “CPT is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs” (AMA 2018). The CPT Editorial Panel in consultation with medical specialty societies represented by the CPT Advisory Committee is responsible for maintaining the terminology.
CPT identifies the services rendered rather than the diagnosis on the claim. The International Classification of Diseases (ICD), which identifies the diagnosis, is discussed later in this chapter. CPT and ICD form units of information about a patient visit in that the diagnosis represented by ICD supports the medical necessity of the service represented by CPT.
CPT is published annually as a print and e-book. It is also available in software applications such as physician practice management systems. Assignment of the CPT code is most often the responsibility of a professional coder based on the healthcare provider’s documentation of the medical services or procedures provided.
CPT Purpose and Use
The purpose of CPT is to provide a uniform language that allows for accurate descriptions of medical, surgical, and diagnostic services. It is designed to communicate consistent information about medical services and procedures among physicians, clinical staff, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
Despite being copyrighted by the AMA, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of the CPT in healthcare data electronic transactions. HIPAA named CPT (including codes and modifiers) as the procedure code set for all but hospital inpatient procedures. CPT codes are the five-character identifiers that represent the service or procedure the individual receives from a healthcare provider. Two-character modifiers indicate the service or procedure performed has been altered by some circumstance but not changed in its definition. Thus, physicians and hospitals must use CPT to report medical and procedure services performed by physicians and other healthcare professionals to public as well as private insurers.
CPT Content and Structure
CPT includes codes, descriptions, and guidelines and covers the breadth of health services physicians provide. Descriptions for evaluation and management services such as a new patient office visit, anesthetic services, surgical procedures, radiology services, pathology and laboratory tests, and medical care are all found in CPT. The Centers for Medicare and Medicaid Services (CMS) categorizes CPT as Level I of the Health Care Common Procedure Coding System (HCPCS) discussed later in this chapter.
CPT is divided into categories: Category I, Category II, and Category III. Category I is the major terminology. It contains a description along with a five-digit code for each service or procedure. Two-digit modifiers are available to qualify the service or procedure. For example, the modifier 50 is used to indicate a bilateral procedure. Criteria for inclusion in Category I include the US Food and Drug Administration has approved the service or procedure, many providers in different locations perform it, and it is clinically effective.
Category I CPT includes the following six main sections:
1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery
4. Radiology
5. Pathology and Laboratory
6. Medicine
The following are examples of Category I CPT services along with their identifiers:
33511 Coronary artery bypass, vein only: 2 coronary arteries
71046 Radiologic examination, chest; 2 views
82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose)
90839 Psychotherapy for crisis; first 60 minutes
Category II CPT is used for performance measurement. This category was created to support data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and have an evidence base as contributing to quality patient care. They represent clinical findings or services where there is strong evidence of contribution to health outcomes and high-quality care. The Level II codes are alphanumeric, consisting of four numbers followed by the letter F. The following is an example of a Category II CPT service along with its identifier:
1065F Ischemic stroke symptom onset of less than 3 hours prior to arrival
Category III CPT is for emerging technologies, services, and procedures. They are considered temporary and they may or may not eventually be moved to Category I. Category III codes are alphanumeric, consisting of four numbers followed by the letter T. The following is an example of a Category III CPT procedure along with its identifier:
0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus
CPT also includes an introduction, an index, and appendices. Within the introduction are section numbers and their sequences and instructions for use of CPT. The index is used to locate a code or code range and is organized by main and modifying terms. Appendices provide information to supplement the main portion of CPT. For example, Appendix A, Modifiers, describes all the modifiers available for use with a CPT code.
Nursing Terminologies
Just as the field of nursing covers a wide range of services, so do the terminologies available to identify those services. The choice of terminology depends on the nursing care documented. In addition, some are location specific. For example, the Nursing Outcomes Classification (NOC) may be used to represent the outcomes of nursing interventions in all settings and the Omaha System is used in the home health setting.
Nursing Terminologies Purpose and Use
Nursing terms provide an effective basis for use in contemporary data systems (Warren 2015, 218). The American Nursing Association (ANA) has specific criteria nursing terminologies must meet to be approved. This includes support of all or part of the nursing process such as assessment and diagnosis. Several organizations, including universities and associations, are responsible for nursing terminology development and maintenance.
The purpose of nursing terminologies is to represent clinical information generated and used by nursing staff (Warren 2015, 207). Nursing terminologies are designed to communicate consistent information about nursing services for a variety of reasons including directing patient care, measuring progress of treatment, as well as for administrative functions, education, and analytical purposes.
Although there is no mandate to use nursing terminologies, the ANA’s board of directors published a position statement regarding the inclusion of recognized terminologies within EHRs as well as other HIT applications. The ANA indicated support for the following recommendations:
· Plan implementation of terminologies
· Obtain consensus on which terminology to use
· Make education and guidance available to assist with choosing the terminology
· Use SNOMED CT and LOINC for problems and care plans when exchanging data among settings
· An exchange between providers using the same terminology requires no conversion to SNOMED CT or LOINC
· A clinical data repository involving multiple terminologies draws from national recognized terminologies of ICD-10, CPT, RxNorm, SNOMED CT, and LOINC (ANA 2018)
Nursing Terminologies Content and Structure
Each nursing terminology covers content specific to its use. Table 5.3 lists the content coverage of some of the ANA-recognized nursing terminologies.
Table 5.3 Content coverage of ANA-recognized nursing terminologies
ANA-recognized nursing terminology
Content coverage
NANDA International
Thirteen domains:
1. Health promotion
2. Nutrition
3. Elimination/exchange
4. Activity/rest
5. Perception/cognition
6. Self-perception
7. Role relationship
8. Sexuality
9. Coping/stress tolerance
10. Life principles
11. Safety/protection
12. Comfort
13. Growth/development
Nursing Interventions Classification (NIC)
Seven domains:
1. Physiological: Basic
2. Physiological: Complex
3. Behavioral
4. Safety
5. Family
6. Health system
7. Community
Nursing Outcomes Classification (NOC)
Seven domains:
1. Functional health
2. Physiologic health
3. Psychosocial health
4. Health knowledge and behavior
5. Perceived health
6. Family health
7. Community health
Clinical Care Classification (CCC)
Two taxonomies:
1. CCC of nursing diagnoses and outcomes
2. CCC of nursing interventions and actions
Omaha System
Three components:
1. Assessment
2. Intervention
3. Outcomes
International Classification for Nursing Practice (ICNP)
Multiaxial representation with seven axes:
1. Focus
