Neehr Perfect Activity: Classifications and Terminology Overview This activity has been developed for the intermediate and advanced EHR user. It explores classification and terminology systems and supports the student's current knowledge of these concepts and terms. The students will apply their knowledge of classification systems by demonstrating not only the associated skills in the EHR, but also the critical thinking skills of interpreting what they discover. The student will use additional resources to complete this activity. Prerequisites 1. Completion of Neehr Perfect Scavenger Hunts Levels I-III 2. Completion of Neehr Perfect Activity: Structured and Unstructured Data (Optional) Student instructions 1. Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to Blackboard (Bb). 2. Screen displays are provided as a guide and some data (e.g. dates and times) may vary. Additional resources 1. Use the website Medline Plus to look up medical terminology you are not familiar with: https://www.nlm.nih.gov/medlineplus/ 2. Use the website ICD10Data to check your answers as needed: http://www.icd10data.com/Convert Objectives 1. Identify the advantages and disadvantages of classification systems used in practice. 2. Identify the functions and relationships between healthcare classification systems. 1 Neehr Perfect EHR Activity: Classifications and Terminology v2 Archetype Innovations LLC 2017 3. Demonstrate simple mapping from ICD-9 to ICD-10. 4. Formulate maps of healthcare terminologies, vocabularies and classification systems. Glossary Classification provides a method of distributing coded concepts in a sorted and meaningful manner. A good classification structure facilitates both immediate and longitudinal data management and retrieval across a number of different groups. Following are the more well known and most commonly used: Healthcare Common Procedure Coding System (HCPCS): Standardized coding system used to identify products, supplies and services not included in the CPT manual. Healthcare Common Procedure Coding System (HCPCS) Level II: Classifies medical equipment, injectable drugs, transportation services, and other services not classified in CPT. Level II to report procedures and services published by a variety of vendors, the coding system is in the public domain. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM): Coding system used to code and classify diagnoses and procedures. International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10): Classification system used for systematic recording, analysis, interpretation, and comparison of mortality and morbidity data from different countries and to translate diagnoses, diseases and other conditions into codes. International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM): Coding system used to report diseases and conditions of US healthcare patients. International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS): Coding system developed to replace Volume 3 of the ICD9-CM manual. International Classification of Diseases for Oncology (ICD-O): Coding system used in tumor or cancer registries for coding the site (topography) and the histology (morphology) of neoplasms. National Drug Codes (NDC): Universal product identifier for human drugs used to identify and report drug products. Current Procedural Terminology (CPT): Coding system established by the American Medical Association for coding of procedures and services. Diagnostic and statistical manual of Mental disorders (DSM): Standard classification of mental disorders used by mental health professionals in the US. 2 Neehr Perfect EHR Activity: Classifications and Terminology v2 Archetype Innovations LLC 2017 Logical Observation Identifiers Names and Codes (LOINC): A free, universal standard for laboratory and clinical observations, and to enable exchange of health information across different systems. Encounters Initial encounter: Patient's initial encounter for active treatment of an injury. Example: The patient is evaluated in the ER for a displaced transverse fracture of the left ulna that cannot be managed at this time. The ER applies immobilization and ice and instructs the patient to follow up with orthopedic. This would be reported using S52.222A Displaced transverse fracture of the left ulna, initial encounter for closed fracture. When the orthopedist rechecks the patient and reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. This is the first encounter at which the patient receives definitive care (the ER was able to provide comfort care). This is again considered an initial encounter and would again report S52.222A for an initial encounter. Subsequent encounter: \"Encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.\" Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment and follow up visits following injury treatment. Sequela: Late effects of an injury. For example: Use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn. Medical terminologies: Are categorized into nomenclatures, which are systematic listings of the proper names. Disease nomenclatures classify and name diseases and other medical terms. Standardized Nomenclature of Disease (SND): Developed by the Anatomical Society. Systematized Nomenclature of Medicine (SNOP): Published by the American College of Pathologists. This system was later expanded into SNOMED. SNOMED RT: A concept based reference terminology providing the infrastructure for the electronic health record worldwide. SNOMED CT: Comprehensive international and multilingual clinical reference terminology. The activity Before moving forward, remember that Neehr Perfect is an \"open source\" version of CPRS (and VistA), which is the EHR used in practice today across the country in the Veterans 3 Neehr Perfect EHR Activity: Classifications and Terminology v2 Archetype Innovations LLC 2017 Administration (VA) hospitals and clinics. Neehr Perfect is a real functioning EHR that has been modified for educational purposes and does not contain 100% of classification codes that you will find in an EHR in practice. Neehr Perfect has ICD-9, ICD-10 and CPT codes, but does not have SNOMED CT. Difference between ICD-9 and ICD-10 Comparison of the Diagnosis Code Sets ICD-9 ICD-10 3-5 characters in length 3-7 characters in length Approximately 13,000 codes Approximately 68,000 available codes First digit may be alpha (E or V) or Digit 1 is alpha; digits 2 and 3 are numeric; digits 2-5 are numeric numeric; digits 4-7 are alpha or numeric Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Has laterality (i.e., codes identifying right vs. left) Here is an example of ICD-9 code structure: 813.80 Unspecified part, (closed) Forearm 813.40 Lower end of forearm, unspecified 813.45 Torus fracture of radius (alone) The expanded number of characters of the ICD-10 diagnosis codes provides greater specificity to identify disease etiology, anatomic site and severity. ICD-10 Code Structure: Characters 1-3 - Category Characters 4-6 - Etiology, anatomic site, severity, or other clinical detail Characters 7 - Extension The following example shows the more detailed information gained through the added characters with the ICD-10 code structure. Using the same problems as above: S52 Fracture of forearm S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S52.521 Torus fracture of lower end of right radius S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture In the above example, S52 is the category. The fourth and fifth characters of \"5\" and \"2\" provide additional clinical detail and anatomic site. The sixth character in this example indicates laterality, i.e., right radius. The seventh character, \"A\Neehr Perfect Activity: Health Information Exchange Overview This activity is intended for the intermediate and advanced EHR student user. This activity will explore health information exchange, what it is, and how it is used. The student will use the HealthIT.gov website and VistA Health Data Systems to complete this activity. Students will answer questions provided in this activity using critical thinking skills. Prerequisites 1. Completion of Scavenger Hunts Levels I - III 2. Completion of the Neehr Perfect EHR Activity: Health Information Terminology 3. Completion of the Neehr Perfect EHR Activity: Introducing HITECH and the History of EHRs Student instructions 1. Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to Blackboard (Bb). 2. Screen displays are provided as a guide and some data (e.g. dates and times) may vary. Objectives 1. Recognize the Veterans Health Information Systems and Technology Architecture (VistA) and its relation to Neehr Perfect. 2. Compare the different forms of information exchange. 3. Explain what a health information exchange is and what it is used for. 4. Identify and use secondary data sources. The activity Go to the website Health IT.gov at http://www.healthit.gov/providersprofessionals/health-information-exchange/what-hie Read each section about Health Information Exchange (HIE): What is HIE? HIE Benefits HIE Governance Nationwide HIE Strategy Standards and Interoperability 1 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Health information exchange (HIE) is the electronic movement of health-related information among organizations according to nationally recognized standards. The goal of health information exchange is to facilitate access to and retrieval of clinical data to provide safer, timelier, efficient, effective, equitable, patient-centered care. Health information exchange organizations (HIOs) provide the capability to electronically move clinical information between disparate health care information systems while maintaining the meaning of the information being exchanged. HIOs also provide the infrastructure for secondary use of clinical data for purposes such as public health, clinical, biomedical, and consumer health informatics research as well as institution and provider quality assessment and improvement. Most HIOs currently are regional health information organizations (RHIOs). Background about the Neehr Perfect EHR The Veterans Health Information Systems and Technology Architecture (VistA) is an enterprise-wide information system built around an Electronic Health Record (EHR), used throughout the United States Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration (VHA). It consists of nearly 160 integrated software modules for clinical care, financial functions, and infrastructure. VistA has been in existence since the 1960s. VistA is widely believed to be the largest integrated HIS in the world. It is designed to provide a high-quality medical care environment for the country's military veterans. VistA has a proven track record of supporting a large variety of clinical settings and medical delivery systems, both inpatient and outpatient. VistA is in production today at hundreds of healthcare facilities across the country from small outpatient clinics to large medical centers and is used by thousands of healthcare professionals. In addition, VistA includes computerized order entry, bar code medication administration, electronic prescribing, and clinical guidelines. The Computerized Patient Record System (CPRS) provides a client-server interface that allows health care providers to review and update a patient's electronic medical record. CPRS organizes and presents all relevant data on a patient in a way that directly supports clinical decision-making. The comprehensive cover sheet displays timely, patient-centric information, including active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization, and outpatient clinic history. This information is displayed immediately when a patient is selected, and provides an accurate overview of the patient's current status before clinical interventions are ordered. CPRS capabilities include: A Real-Time Order Checking System that alerts clinicians during the ordering session that a possible problem could exist if the order is processed; A Notification System that immediately alerts clinicians about clinically significant events; A Patient Posting System, displayed on every CPRS screen, that alerts clinicians to issues related specifically to the patient, including crisis notes, warning, adverse reactions, and advance directives; The Clinical Reminder System, which allows caregivers to track and improve preventive health care for patients and ensure timely clinical interventions are initiated; and 2 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Remote Data View functionality that allows clinicians to view a patient's medical history from other VA facilities to ensure the clinician has access to all clinically relevant data available at VA facilities. This function is inactive in the student version, Neehr Perfect. Neehr Perfect is CPRS. VistA CPRS Neehr Perfect VistA Health Data Systems Health Data Systems (HDS) provides complete, accessible, longitudinal, veterancentric data to the end-user applications of the enterprise. This work is accomplished through four major program areas: Standards & Terminology Services Repositories Registries 3 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Health IT Sharing Standards & Terminology Services (STS) develops, implements, and maintains authoritative data standards, and enables the interoperability and exchange of standardized and computable information between VA information technology systems and with government and private health care partners. The Repositories Program supports storage of enterprise-wide, veteran-centric clinical and administrative data. The HDR Data Warehouse meets the data needs of the VA research and analysis community without impacting database performance for the end-users. The Registries Program supports the population-specific data needs of the enterprise including, but not limited to, Oncology Tumor Registry, Traumatic Brain Injury Registry, Embedded Fragment Registry and Eye Trauma Registry. The Healthcare Associated Infection and Influenza Surveillance System (HAIISS) monitors data in VA's integrated IT systems to identify potential disease, bioterrorism, or healthcare-associated infection outbreaks. The Clinical Case Registries (CCR) application contains demographic and clinical data on VHA patients with certain clinical conditions. CCR is designed to allow multiple registries to be supported to track a variety of clinical conditions or disease states. The Hepatitis C Case Registry contains important demographic and clinical data on VA patients identified with Hepatitis C infection. The registry extracts VistA pharmacy and laboratory data to provide key clinical information. Data from the Hepatitis C Case Registry are used on the national, regional, and local level to track and optimize clinical care of Hepatitis C infected veterans served by VA. The Human Immunodeficiency Virus (HIV) Case Registry contains important demographic and clinical data on VHA patients identified with HIV infection. It accesses several other VistA files that contain information regarding diagnoses, prescriptions, surgical procedures, laboratory tests, radiology exams, patient demographics, hospital admissions, and clinical visits. This access allows identified clinical staff to take advantage of the wealth of data supported through VistA. The Oncology Tumor Registry supports tumor registrars in abstracting cancer cases, following up on cancer patients, and producing the Hospital Annual Report. Functions are grouped according to order of use: Case Finding and Suspense; Abstracting, Printing and Quality Management; Follow-up; Registry Lists; Annual Reports; Statistical Reports; and Utilities. The Oncology Registry functions in accordance with the current editions of American College of Surgeons (ACOS) requirements. The Embedded Fragment Registry is required by the Presidential Task Force on Returning Global War on Terror Heroes in support of the VA Toxic Embedded Fragment Surveillance Center (TEFSC). The embedded fragment registry is used to track and report care provided to these service members experiencing such injury. Health Information Technology Sharing (HITS). The ability to share data across agencies and facilities is an important component in providing the complete information necessary for clinical decision-making and high-quality veteran care. 4 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 This includes the sharing of standardized data adds the capability of utilizing computable data in automated processes such as orders checks and other electronic decision support applications. Another feature is the tracking of patient medications and allergies. These were two of the first content areas (patient medications and allergies) to be shared enabling drug-drug and drug-allergy order checks based on patient data. Examples of technology sharing currently in use at the VA centers using the VistA system are: Federal Health Information Exchange (FHIE) Bi-Directional Health Information Exchange (BH I E) Clinical Health Data Repository (CHDR) Laboratory Data Sharing and Interoperability (LDSI) Global War on Terror - Big 7 1. Understanding what the Health Information Exchange is, explain how the repositories and registries of the Health Data Systems provide safer, timelier, efficient, effective, equitable, patient-centered care? Direct exchange With the direct exchange of healthcare information a primary care provider can directly send electronic care summaries that include medications, problems, and lab results to a specialist when referring their patients. This information helps to inform the visit and prevents the duplication of tests, redundant collection of information from the patient, wasted visits, and medication errors. In Neehr Perfect, select the chart Vivian Armand, choose the Help menu and search for Remote Data. Read the information provided about Remote Data and answer the following question. 2. Why do you think the Remote Data button is not activated in this educational EHR? Understanding that one of the key aspects of health information exchange is the timely sharing of vital patient information, let's think about the three ways of information exchange and how they appear, or may not appear, in Neehr Perfect. 5 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Query-based exchange Emergency room physicians who can utilize query-based exchange to access patient informationsuch as medications, recent radiology images, and problem listsmight adjust treatment plans to avoid adverse medication reactions or duplicative testing. 3. As a student you have access to outside resources such as the Drug Information Portal, Health Information and Lab Tests Online in the Tools menu of Neehr Perfect. These resources could assist you in teaching a patient about giving themselves injections, looking up a medication the patient is taking, or understanding the implication of a high lab value. Can you think of other ways having these resources, and others like them, available to any healthcare professional would be an advantage or an improvement on patient care? Consumer-mediated exchange 4. In Neehr Perfect explore Vivian Armand's chart. Imagine you were her and you had received copies of your entire medical record. You are now looking at the information in there: the problems, the medications, the notes, the lab results... Would you like being able to see all of your health record? For example, being able to see what healthcare professionals wrote in notes about you or your health. Why or why not? Explain if there would be advantages or disadvantages. 5. Now put yourself in the place of the physician or nurse caring for Vivian Armand. Would it be more understandable to only allow Vivian to view certain parts of the chart, for example her current medication list and current lab or test results? Why or why not? Explain if there would be advantages or disadvantages. 6 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Submit your work Document your answers directly on this document as you complete the activity. When you are finished, save this document. Upload it to Bb. References HealthIT.gov. Retrieved June 27, 2013 from http://www.healthit.gov/providersprofessionals/health-information-exchange/what-hie United States Department of Veterans Affairs (Sept. 21, 2011). Retrieved on June 30, 2013 from http://www.va.gov/vista_monograph/ U.S. Department of Health and Human Services: Health Information Technology and Quality (2012). Retrieved June 30, 2013 from www.hrsa.gov/healthhit/toolbox/RuralHealthITtoolbox/Collaboration/whatishie. html 7 Neehr Perfect EHR Activity: Health Information Exchange v5 Archetype Innovations LLC 2017 Neehr Perfect Activity: SNOMED CT Overview This activity has been developed for the intermediate and advanced EHR user. It is a continuation of the Neehr Perfect Classifications and Terminology activity. In this activity, SNOMED CT is discussed. This will build on the student's current knowledge of standardized concepts, classifications and terminology. The student will use additional resources to complete this activity. Prerequisites 1. Completion of Scavenger Hunts Level I - III 2. Neehr Perfect Activity: Classifications and Terminology 3. Neehr Perfect Activity: Structured and Unstructured Data (optional) Student instructions 1. Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to Blackboard (Bb). 2. Screen displays are provided as a guide and some data (e.g. dates and times) may vary. Additional resources 1. I-Magic, http://imagic.nlm.nih.gov/imagic/code/map 2. Medline Plus, https://www.nlm.nih.gov/medlineplus/ 3. ICD10Data, http://www.icd10data.com/Convert Objectives 1. Explain the purpose of SNOMED CT. 2. Identify advantages and possible disadvantages with implementing multiple classification systems. 3. Identify the functions and relationships between healthcare classification systems. 4. Categorize, or map, terminologies, vocabularies and classification systems. Glossary SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms): is a standard clinical terminology with specific support for multi-lingual translation. It is in use in more than fifty countries. It is owned, maintained and distributed by the International Health Terminology Standards Development Organization (IHTSDO). 1 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 The activity SNOMED CT is a terminology that can cross-map to other international standards and classifications. It currently contains more than 300,000 medical concepts, divided into hierarchies as diverse as body structure, clinical findings, geographic location and pharmaceutical/biological product. Each concept is represented by an individual number and several concepts can be used simultaneously to describe a complex condition. By using numbers to represent medical concepts, SNOMED CT provides a standard by which medical conditions and symptoms can be referred to. SNOMED CT is designed to be managed by a computer. It's not just a flat list of numbers and corresponding terms. It's a complex relationship of concepts. 2 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 The hierarchy of SNOMED CT: Body structure: Normal (e.g. Entire femur) or abnormal (e.g. Vascular polyp) body structures. Clinical finding: Outcomes of clinical observation, assessment, or judgment, as well as normal and abnormal (e.g. Pulse fast) states. Environment or geographical location: Refers to different types of environments (e.g. Intensive care unit, toxic environment, cold zone) and locations such as countries, states, and regions (e.g. Burundi, Arizona, Island in the region of North America). Event: Occurrences (e.g. Accident, exposure to carbon dioxide, air travel, environmental event). Procedures and interventions are excluded from this category. Observable entity: Entities that can be measured or observed (e.g. Age at first symptom, blood pressure, body temperature). Organism: Organisms that are relevant in human and veterinary medicine such as animals (e.g. Canis lupus familiaris), plants (e.g. Amaryllis), life-cycle forms (e.g. Bacterial spore), trophic life forms (e.g. Carnivore), chromista (e.g. Oomycota), and microorganisms (e.g. Fungus). Pharmaceutical/biological product: Drug products (e.g. Oral form aspirin, alcoholic disinfectant, lavender oil). Physical force: Different kinds of physical influences that are connected to injury. Examples: Detonation, air and water pressure, radiation, mechanical stress. Physical object: Devices (e.g. Industrial machine), materials (e.g. Leather), instruments (e.g. Firearm), vehicles (e.g. Snowmobile) and other natural or manmade objects (e.g. Hospital bed, silver jewelry). Procedure: Activity in the healthcare sector such as administrative (e.g. Death certification, Formal complaint about GP), invasive (e.g. Removal of wart), diagnostic (e.g. Complete blood count), imaging (e.g. Radiography of shoulder), 3 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 educational procedures (e.g. Diet education), as well as referrals (e.g. Referral by clinical oncologist). Qualifier value: Qualifier value concepts are used as values for other SNOMED CT attributes. For example, the values for specifying the laterality of an ulnar fracture (i.e. Left, right) are contained here. Record artifact: Documents that were created to provide information about healthcare related events or states of affairs (e.g. Anesthesia record, birth certificate). Situation with explicit context: Concepts in this hierarchy specify the circumstances of a procedure, a finding, or a condition. They refer to procedures and conditions in the past (e.g. Injection given) or future (e.g. Awaiting radiotherapy), findings that can be ruled out (e.g. No cardiovascular symptom), or information about someone other than the patient (e.g. Family history of alcoholism). SNOMED CT Model Component: Core metadata concepts (provides structural information for international releases), foundation metadata concepts (reference sets, reference set attributes), linkage concepts (attributes, link assertions), namespace concepts, module concepts (e.g. national extensions), etc. Social context: Social aspects that may influence health and treatment of a patient. Concepts refer to social status (e.g. Lower middle class economic status), ethnic group (e.g. Caucasian), religion (e.g. Anglican), life style (e.g. Eating habit), family (e.g. Divorced parents), and occupation (e.g. Factory worker). Special concept: Inactive concepts (e.g. outdated concept) as well as some navigational concepts. Specimen: Samples or specimens that were acquired for examination or analysis. Examples: Blood sample, genetic sample, environmental swab, specimen from bone marrow obtained by biopsy. Staging and scales: Concepts in this hierarchy refer to different instruments of testing and scaling: Assessment scales (e.g. Stanford Binet intelligence scale), classifications (e.g. Endometriosis classification of American Fertility Society), grading systems (e.g. Nottingham histologic grading system), symptom ratings (e.g. Chest pain rating) and tumor staging (e.g. Cancer staging). Substance: Substances and chemical elements that are used for pharmaceutical and biological products, as well as body, dietary, and diagnostic substances. Examples: Diclofenac, melatonin, urine protein, swimming pool water. To explore the content of SNOMED CT, when SNOMED CT is not implemented in an EHR, an online browser is used. A couple of examples are http://browser.ihtsdotools.org/ and http://www.medicalclassifications.com/TheSNOMEDCTbrowser/ SNOMED CT vs. ICD SNOMED CT is different from ICD-10. SNOMED CT is clinical terminology designed for direct use by healthcare providers during the process of providing care. It is designed for input. SNOMED CT includes more than 300,000 concepts, 790,000 descriptions, 19 hierarchies, and 920,000 relationships. ICD codes, on the other hand, are designed to be used by coding professionals once the episode of care (the encounter) is completed. The code captures the 4 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 diagnosis or problem. ICD codes are designed for output. ICD-10 currently includes more than 150,000 codes. SNOMED CT and Electronic Health Records When talking about SNOMED CT in terms of use with an Electronic Health Record (EHR), SNOMED CT improves communication and increases the availability of health information. If clinical information is stored in the EHR in ways that allow meaning-based retrieval (structured data entry), the benefits are greatly increased. The added benefits range from increased opportunities for real time decision support to more accurate retrospective reporting for research and management. SNOMED CT supported clinical health records benefit individuals by: Enabling relevant clinical information to be recorded using consistent and common descriptions. Enabling decision support systems to check the record and provide real-time advice. Support the sharing of appropriate information with healthcare providers for a specific patient through data capture that is universally understood. Permitting comprehensive searches that identify patients who require follow-up or changes of treatment based on revised guidelines. Removing language barriers by enabling multilingual use. SNOMED CT supported clinical health records benefit populations by: Facilitating early identification of emerging health issues, monitoring of population health and response to evolving healthcare practices. Enabling targeted access to relevant information. Reducing costly duplications and errors. Enabling the query of relevant data to support clinical research. Optimizing audits of healthcare delivery documented in patient health records. SNOMED CT supported health records inform evidence-based healthcare decisions by: 5 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 Enabling links between clinical records and enhanced clinical guidelines and protocols. Improving the quality of care experienced by individuals. Reducing costs of inappropriate and duplicative testing and treatment. Limiting the frequency and impact of adverse healthcare events. Raising the cost-effectiveness and quality of care being delivered. Implementation of SNOMED CT can help providers with the transition to ICD-10, because computer systems can use SNOMED CT content to seamlessly generate ICD-10 codes. Computer systems designed for this purpose use a mapping system to suggest recommended ICD-10 codes based on SNOMED CT codes and, if applicable, additional information obtained from the electronic patient record or from direct user input. The healthcare provider or professional coder should then review the recommended ICD-10 codes for accuracy. Mapping in practice In practice, SNOMED CT is a terminology that can cross-map to other international standards and classifications. The purpose of mapping is to provide a link between one terminology to another. SNOMED CT mapping is designed to be integrated into a computerized patient record (an EHR). Clinical information recorded using SNOMED CT may include data that is relevant to reports, statistical returns, billing claims, etc. that need to be encoded using a specific code system or a statistical classification such as ICD-10. A simplified example of mapping: The following is a screen shot of how a provider documents a patient's problems in the EHR (at Indian Health Services). In this example, the provider selects the SNOMED CT term that best fits the patient's condition (the input) with the EHR having automatically mapped it to the appropriate ICD-10 code. Then the ICD-10 code is used for billing purposes (the output). 6 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 There are a number of independent online mapping tools and built in mapping tools (built into EHRs) available to complete the association between SNOMED CT and ICD codes. Some experts believe that implementation of SNOMED CT will help providers with the transition to ICD-10, because computer systems can use SNOMED CT content to seamlessly generate ICD-10 codes. Because these two terminologies are \"synergistic\" when used concurrently, many EHR vendors are implementing SNOMED CT and ICD-10 simultaneously. For example, advanced conversion tools enable ICD-10 codes to be dragged easily from an electronic superbill to the problem list and automatically translated to SNOMED CT and vice versa. 1. Use the I-Magic interactive program from the National Institutes of Health, Department of Health and Human Services, to map patient problems. Copy and paste the following link to the I-Magic program into your internet browser, http://imagic.nlm.nih.gov/imagic/code/map. I-Magic is a free, simple, online, interactive program that will assist in better understanding mapping. Click on the Demo tab in the upper right corner. 7 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 Next, open a new tab or page in your browser. Log in to Neehr Perfect and launch the EHR. Select the chart of Melinda Goble. If you see \"POR,\" \"Visit Not Selected\" or \"Current Provider Not Selected\" at the top of your chart in the box to the right of Melinda Goble's name, double click on the box. In the pop-op window, select your faculty as the Provider. Choose the Family Clinic and leave the date for Now. Then click OK. Melinda has four problems identified in her chart. However, they are coded with ICD-9s or do not have specific codes assigned to the problem (799.9). Use the EHR to map (or convert) the ICD-9 name and code to an ICD-10. You will be completing this manually. Refer to the previous activity, Classifications and Terminology, on how to locate ICD-10 codes in Neehr Perfect. You may also use other resources such as textbooks and online websites. Use the I-Magic website to complete the mapping process with SNOMED CT. Complete the table below. Using the I-Magic website: Enter the following information: Name: leave as \"My Patient (modified)\" Gender: Female Date of Birth: Enter Melinda's DOB (for example, 02/28/1973) Add \"Problem\": Add the name of the ICD-10 problem. It will not accept the ICD10 code for a search. Click on Update List. If asked to clarify the concept for SNOMED CT, select the closest term that matches the ICD-10 name or re-enter the name. Then click on Get ICD Codes. Hint: As you are provided the SNOMED CT code, confirm that it is mapping to the same ICD-10 code that you selected in Neehr Perfect. Problem Name & ICD-9 code 8 Problem Name & ICD10 code Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 SNOMED CT Name & Code Critical thinking questions \"Seamless\" electronic mapping between code sets supports improved employee productivity and accuracy. This is done by eliminating the time associated with identifying the correct SNOMED CT or ICD-10 code through a manual process. 1. Identify and then describe one advantage and one disadvantage to implementing both SNOMED CT and ICD-10 in an electronic format in a clinic setting. Provide details and examples to support your answers. List references for any additional resources you used. a. Advantage: b. Disadvantage: Meaningful Use Stage 2 discusses using SNOMED CT codes for the documentation of a person's smoking status in the EHR ( 170.314(a)(11) Smoking Status). The measure states \"Below is the corresponding certification and standards criteria for electronic health record technology that supports achieving the meaningful use of this objective.\" a. Current every day smoker. 449868002 b. Current some day smoker. 428041000124106 c. Former smoker. 8517006 d. Never smoker. 266919005 e. Smoker, current status unknown. 77176002 f. Unknown if ever smoked. 266927001 g. Heavy tobacco smoker. 428071000124103 h. Light tobacco smoker. 428061000124105 2. Explain how this Meaningful Use requirement might impact a clinic that does not have SNOMED CT incorporated into their EHR yet. For example, how will this affect the coding process for filing claims when ICD-10 codes are used for billing? Provide details and examples to support your answers. List references for any additional resources you used. Submit your work Document your answers directly on this document as you complete the activity. When you are finished, save this document and upload it to Bb. 9 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017 References Fung, K.W. (2012) How SNOMED CT can help in the ICD-10-CM transition. American Health Information Management Association. Retrieved from www.nlm.nih.gov Helwig, A. (2013). EHR Certification Criteria for SNOMED CT will help doctors transition to ICD-10. Health IT Buzz. Retrieved from http://www.healthit.gov/buzzblog/electronic-health-and-medical-records/ehr-certification-criteria-snomed-ctdoctors-transition-icd10/ Jamoulle, M. (2010). Some views about SNOMED-CT by a General Practitioner. Retrieved from http://docpatient.net/onto/doc/SNOMED_CT_study_MJ_2010.pdf Levy, B. (2015). Intersection of ICD-10 and meaningful use: Clinical documentation improvement. Government Health IT. Retrieved from http://www.govhealthit.com/news/intersection-icd-10-and-meaningful-use-clinicaldocumentation-improvement SNOMED CT Starter Guide (2014) International Health Standards Development Organisation (IHTSDO) http://ihtsdo.org/fileadmin/user_upload/doc/download/doc_StarterGuide_Currenten-US_INT_20140222.pdf Snow Owl User Guide. Retrieved from https://b2i.sg/help/index.jsp?topic= %2Fcom.b2international.snowowl.help%2Feclipsehelp %2FGetting_Started_with_Snow_Owl%2FSurfing-the-sea-of-SNOMED-CT-Browsingand-searching-with-Snow-Owl.html Stage 2 Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 4 of 16 (2012). Centers for Medicare and Medicaid Services. Retrieved from https://www.cms.gov 10 Neehr Perfect EHR Activity: SNOMED CT v2 Archetype Innovations LLC 2017