Chapter 6 : Classification Systems, Clinical Vocabularies, And Terminology

Front 1

Basic Interoperability

Back 1

Allows a message from one computer to be received by another, but does not require the receiving computer to be able to interpret the data. This might be viewed as technical connectivity. It is analogous to putting a letter in an envelope and mailing it. The letter gets from the sender to the recipient. It does not matter what is in the envelope.

Front 2

Functional Interoperability

Back 2

Defines the format of messages. This ensures 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, however, has understanding of the meaning of the data within the fields. This is similar to e-mail in that the format is agreed on w/ To/From/Subject/Message. Like basic interoperability, technical connectivity is achieved and must follow a standard format, but the system is not trying to understand the meaning of the messages.

Front 3

Semantic Interoperability

Back 3

Provides common interoperability, that is, information within the data fields can be used intelligently. It has the ability to allow information to be understood by shared systems. This level of interoperability is dependent on the degree of agreement of data terminology and its quality. An ex of this is found at Methodist University Hospital, where they use robots in their pharmacy. Because they use semantic interoperability, various fields mean the same thing across systems. This enables CPOE (computerized physician/provider order entry) info to be understood by robots.

Front 4

Interoperability

Back 4

The ability to communicate & exchange data accurately, effectively, securely, and consistently w/ different info tech systems, software apps, & networks in various settings, & exchange data such that clinical or operational purpose and meaning of the data are preserved & unaltered.

Front 5

Interoperability: Application Level

Back 5

Means the capacity of an authenticated user to access & transmit or receive & exchange usable info w/ others.

Front 6

Interoperability: Systems Level

Back 6

Means the ability of diff info systems & software apps to communicate & exchange data accurately, effectively, & consistently. It includes the ability to use the info that has been exchanged.

Front 7

Interoperability: Expanded Level

Back 7

Means the ability of health info systems to work together within & across organizational boundaries & disparate systems to other authorized entities in real time.

Front 8

"Unstructured" data or free text

Back 8

The process of entering data information directly online or may continue to dictate their notes directly or w/ voice dictation.

EX: Order form for text directly

Front 9

"Structured" data

Back 9

Entry that allows users to draw from standard phrases or pick lists and pull down menus to help guild the entry and ensure that complete info is included.

EX: Consult order w/ selections in dropbox

Front 10

Vocabulary

Back 10

All the terms that are recognized for communication within a domain; it is a collection of words or phrases

Front 11

Reference controlled terminology

Back 11

a concept based, controlled medical terminology; identifies relationship btw concepts -- relationship can be hierarchical. Reference terminology allows healthcare systems to get value from clinical data at the point of care. It creates links between medical concepts that support data queries.


EX: SNOMED-CT

Front 12

Classification System

Back 12

A scheme for grouping similar things in a logical way on the basis of common characteristics. Focus on collecting and reporting health stats and assisting outcomes analysis. EX: ICD

Front 13

Nomenclature

Back 13

A naming convention or systemic listing of names that have been assigned according to pre established rules. A classified system of technical or scientific names.
EX: SNOP

Front 14

Controlled Vocabulary

Back 14

Means the terms within the vocabulary are carefully selected for their inclusion; terms outside the boundaries not included.
EX: ICD-9-CM

Front 15

What is meant by specificity and granularity as these terms relate to classification systems? Use ICD-9 versus ICD-10 to illustrate.

Back 15

Classification systems vary in their level of details; some offer very general grouping, whereas others allow more detailed grouping and subgrouping, enabling the user to capture a greater degree of specificity, or granularity, of data.
EX: There is only one code for angiography in ICD-9. However, ICD-10 provides 1,170 coded descriptions that can identify the location of the blockage & the device used.

Front 16

Why are classification systems used to support statistical analysis and reporting?

Back 16

Because the system is intentionally limited to a relatively small number of mutually exclusive categories.

Front 17

Terminology

Back 17

Generally means a set of terms representing the system of concepts of a particular subject or field. Terminologies have been developed to represent diseases, procedures, medications, devices, anatomy, functional status, etc.

Front 18

Administrative Terminologies

Back 18

Classification and coding systems that are primarily designed to support the administrative, financial, and regulatory functions ass. w/ patient care.

Front 19

Clinical Terminologies

Back 19

Designed to represent the information in the patient record, whether in paper or e-form. Each term is represented as a concept and has a code.

Front 20

Describe the function of the interpretative layer of a controlled clinical reference terminology.

Back 20

An interpretive later of semantics btw the term entered by the user and the underlying database to better represent the original intention of the terms of the user. This helps others to understand the entry made by the author in the way it should be interpreted.

Front 21

Explain what is meant by data mapping.

Back 21

The process of creating data element mappings between semantic and representational terms residing in 2 distinct data models. Helps systems recognize terms and their possible synonyms.

Front 22

Describe the purpose and limitations of GEMS.

Back 22

To ensure that consistency in national data is maintained. A comprehensive translational dictionary that can be used to convert ICD codes from one version to the next and visa versa. GEMs are not a one-to-one crosswalk.