Health Data Content

Health Data Content and Structure HITT 1301


Assignment 1:


Watch the video “99 Differentials”

Identify the medical content mentioned in the video, determine which clinical terminologies, classifications, and code system would be used to capture the content; and describe their findings.


Turn in your typed one (1) page assignment in a word document, Times New Roman Times in a font size of 12.






Assignment 2:


1. If the data use were to allow different providers the ability to send and receive medical data in an understandable and usable manner, would a clinical terminology, classification or code system be necessary? Why?

1. SNOMED CT and CPT are both clinical terminologies, how is their content similar? Different

1. Which of the codes systems are for primary data collection? Which are for secondary collection? Why


Turn in your typed one (1) page assignment in a word document, Times New Roman Times in a font size of 12.






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 (


ISBN: 978-1-58426-720-1

AHIMA Product No.: AB103118












Key Terms






Clinical terminology


Code set


Code system


Common Clinical Data Set (CCDS)




Data set


Derived classification




Extension codes


Fully specified name (FSN)




Granular level


Health information exchange (HIE)


International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics (ICD-11-MMS)


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








Preferred term (PT)


Reference terminology


RxNorm concept unique identifier (RXCUI)


Semantic interoperability


SNOMED CT identifier (SCTID)


Stem codes


Unified Medical Language System (UMLS)









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.


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