Healthcare Terminologies and Classifications
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Healthcare Terminologies and Classifications: An Action Agenda for the United States American Medical Informatics Association and American Health Information Management Association Terminology and Classification Policy Task Force Acknowledgements AHIMA and AMIA Terminology and Classification Policy Task Force Members Keith E. Campbell, MD, PhD The American Health Chair, AHIMA and AMIA Terminologies and Classifications Policy Task Force Information Management Chief Technology Officer, Informatics, Inc., and Assistant Clinical Professor; Association (AHIMA) is the Department of Medical Informatics and Clinical Epidemiology, Oregon Health and premier association of health Science University information management Suzanne Bakken, RN, DNSc, FAAN (HIM) professionals. AHIMA’s Alumni Professor of Nursing and Professor of Biomedical Informatics School of 51,000 members are dedicated to Nursing and Department of Medical Informatics, Columbia University the effective management of personal health information Sue Bowman, RHIA, CCS needed to deliver quality Director of Coding Policy and Compliance, American Health Information healthcare to the public. Management Association Founded in 1928 to improve the quality of medical records, Christopher Chute, MD, PhD AHIMA is committed to Professor and Chair of Biomedical Informatics, Mayo Foundation advancing the HIM profession in an increasingly electronic and Don Detmer, MD, MA President and Chief Executive Officer, American Medical Informatics Association global environment through leadership in advocacy, Jennifer Hornung Garvin, PhD, RHIA, CPHQ, CCS, CTR, FAHIMA education, certification, and Medical Informatics Postdoctoral Fellow Center for Health Equity Research and lifelong learning. To learn more, Promotion, Philadelphia Veterans Administration Medical Center go to www.ahima.org. Kathy Giannangelo, MA, RHIA, CCS, CPHIMS Director, Practice Leadership, AHIMA Gail Graham, RHIA The American Medical Director, Health Data and Informatics Department of Veterans Affairs Informatics Association (AMIA) Stanley M. Huff, MD is the premier organization in Professor of Medical Informatics, University of Utah Senior Medical Informaticist, the United States dedicated to Intermountain Healthcare the development and application of medical informatics in the Linda Kloss, MA, RHIA, FAHIMA support of patient care, teaching, Chief Executive Officer, AHIMA research, and healthcare administration. AMIA links Margaret Skurka, MS, RHIA, CCS developers and users of health Professor and Director of Health Information Programs, Indiana University Northwest information technology, creating Mary Stanfill, RHIA, CCS, CCS-P an environment which fosters Vice President, Practice Resources, AHIMA advances that revolutionize healthcare. To learn more, go to Valerie Watzlaf, PhD, RHIA, FAHIMA www.amia.org. Associate Professor, Department of Health Information Management, School of Health and Rehabilitation Sciences, University of Pittsburgh Healthcare Terminologies and Classifications: An Action Agenda for the United States Table of Contents Executive Summary . .4 Background . .5 Magnitude of the Problem . .7 The Vision and Goals for the US . .9 What to Do Next . .15 Role of AHIMA and AMIA . .18 Conclusion . .19 Table 1: Governance of Various Terminology Systems . .20 Table 2: Development and Maintenance of Various Terminology Systems . .23 Appendix A: Australia, the United Kingdom, and Canada . .27 Appendix B: Terminology Services and Tools . .29 Table 3: Terminology Services and Tools in Four Organizations . .30 Glossary . .32 3 This white paper is a revised version of a paper originally released by AHIMA and AMIA in 2006. ©2007 Healthcare Terminologies and Classifications: An Action Agenda for the United States Executive Summary committed to the development of the emerging national health information system. But both Terminologies and classifications form the organizations recognize that additional foundations of information content in the resources and appropriate funding are needed electronic health record (EHR) and are the to build on initial work for healthcare basis for research, public health reporting, and terminologies and classifications strategy, healthcare payment.1 They are integral to governance, and development and interoperability and, thus, a successful national maintenance processes. health information system that promises To address these issues, AHIMA and AMIA increased patient safety and reduced costs. convened a Terminology and Classification Although there has been significant progress in Policy Task Force composed of experts in the United States to better understand the role medical and nursing informatics (a field that terminologies play in our health information studies the support of medicine by information systems, and to make terminologies more systems), health information management broadly available in machinable forms, more professionals, experts in nosology (the branch must be done to ensure that this progress of medicine that deals with the classification of serves as a robust foundation for the diseases), and educators. The group’s goal was information content of the EHR. to develop recommendations for the major challenges that would help establish a process The healthcare industry–including the that results in interoperability. The Task Force government, professional organizations, public has formulated a vision and associated goals and private institutions, and health informatics and recommendations that it hopes will be and information management professionals– used to frame a public-private dialogue about must address the issues before the US how to redesign the US approach to healthcare healthcare system is marginalized. To not do so terminologies and classifications against a would mean continued reliance on poor- backdrop of international approaches and quality data for decision making and the achievements. spending of dollars to retrofit a system that is 4 obviously broken. The vision consists of the following: This report describes challenges that require • US governance occurs from a national action. It proposes the formation of a perspective against a backdrop of centralized terminology authority, and other international agendas. steps, to address these challenges. • US policy coordinates with other countries, and the US actively collaborates Task Force Vision and and shares costs. Recommendations • Coordination and collaboration occurs The American Medical Informatics Association with international terminology and (AMIA) and the American Health Information classification development and Management Association (AHIMA) are pleased maintenance initiatives. with the progress made thus far and are 1. For purposes of this report, an EHR is defined as an information system designed to provide access to complete and accurate clinical data, practitioner alerts and reminders, clinical decision support systems, and links to medical knowledge. Giannangelo, K. (Ed). Healthcare Code Sets, Clinical Terminologies, and Classification Systems. AHIMA. [Note: Within this definition, a personal health record (PHR) only qualifies as an EHR if it is part of an EHR having the identified capabilities.] Healthcare Terminologies and Classifications: An Action Agenda for the United States • Terminologies, classifications, and maps terminology and classification form a coherent set of policies and development and maintenance, including procedures for openness and ensured the supporting systems. performance. • Develop a governance model for the • Transparency of process exists even when central authority that is accountable to the the development organization maintains needs of the end users and implementers, the system within its own organization. and also has accountability for the funding of the central authority. • Infrastructure for development and maintenance of the terminology is subject • Commit to the adoption of sound to an open process. principles for operation of a terminology and classification standards development • Business process automation is organization. implemented, allowing organizations to participate and track the terminology and The Task Force believes that the items on this classification development processes, agenda must be accomplished. To this end, reducing cost, and automating many AHIMA and AMIA are ready to lead, in aspects of the system release cycles. concert with the appropriate government agencies, the US effort for terminologies and To implement this vision, the Task Force classification reform. They recognize the US recommends that the healthcare industry— agenda for health information reform will government, public and private institutions, require strong public and private collaboration. and professional organizations— In the months to come, AHIMA and AMIA collaboratively undertake the following tasks: will convene stakeholders to build a broader • Create a publicly funded research and understanding of the current problems, development project to prepare generate wide support for, and begin to specifications for coordinated solutions construct a road map for change. and where possible, consolidate terminology. • Secure funding for the planning and 5 development of a centralized authority, representing both public and private stakeholders, to manage the funding and be responsible for overseeing US Healthcare Terminologies and Classifications: An Action Agenda for the United States Healthcare Terminologies and Classifications: An Action Agenda for the United