Terminology Recommendations MMI 405

Francisco E. Figueroa

Current Status of Standard Terminologies

Our work as consultants primarily involve implementing CRM systems to consolidate

clinical and administrative data from EHRs and health plans for patient care coordination,

medical tourism, transitional care, aftercare and case management. In the case of a hospital

setting, they are using Mckesson Paragon EHR using ICD 10, CPT and LOINC to capture data

associated to problem lists, medical history, procedures, medical orders, and test results. In the

case of medications, they are using RxNorm. The system can handle SNOMED but they are

only using ICD. In the case of the health plan, the data we gather is based on ICD, CPT, and

NDC only. In another project, we are working to establish a centralized system to capture all

test results of Puerto Rico for abnormalities identification, patient and provider notification. In

addition, this data will be used to analyze health population the data we are receiving include

terminology type, LOINC or CPT. Depending on the laboratory information system vendor we

get the CPT or LOINC code.

Medications Domain

For the medications domain, I propose RxNorm. According to the U.S National Library

of Medicine, RxNorm is a standardized nomenclature for clinical drugs produced by the National

Library of Medicine. RxNorm has standards name for clinical drugs. The Rxnorm is a more

comprehensive database than the NDC. (UMLS, 2012). RxNorm represents the drugs in a way 1

that corresponds to the prescriber’s view, as an ingredient, strength and dose form. 2

Clinical and Laboratory Observations Domain

For clinical and laboratory observations, I propose the use of LOINC. According to

LOINC.org, LOINC is a common language (set of identifiers, names, and codes) for clinical and

laboratory observations. It is a catalog of measurements, including laboratory tests, clinical

measures like vital signs and anthropometric measures, standardized survey instruments, and

more. The benefit of LOINC is that enables the exchange and aggregation of clinical results.

This aggregation of results can be used for care delivery, outcomes management, care

coordination, transition care, health population management and research through the use of

universal codes and structured names to identify things you can measure or observe. 3

Classification and Billing

To classify, diseases, signs and symptoms, abnormal findings, complaints, social

circumstances and external causes of injury or diseases, as classified by the World Health

Organization (WHO), ICD 10 is a good system that can be integrated with a SNOMED mapping

to integrate both clinical and administrative purposes. According to Medicaid.gov, ICD-10 is an

updated version of the ICD-9 code sets. Several countries have taken the ICD-10 code set and

modified it for use in their medical systems. In the case of the United States, has developed the

ICD-10-CM (or Clinical Modification) version of the code set for use in the US. This code set

1 UMLS. RxNorm Technical Documentation. Version 2012-1. January 03, 2012. Retrieved from https://www.nlm.nih.gov/research/umls/rxnorm/docs/2012/rxnorm_doco_full_2012-1.html 2 Halamka, J. The Benefits of RxNorm. Life as a Healthcare CIO. Retrieved from http://geekdoctor.blogspot.com/2011/11/benefits-of-rxnorm.html 3 LOINC.org. About LOINC. Retrieved from https://loinc.org/background

was developed through the National Center for Health Statistics. The Centers for Medicare &

Medicaid Services (CMS) has created a new code set, ICD-10-PCS (or Procedure Coding

System), for use. 4

The other terminology standard to use in combination with the ICD-10 for medical

billing process in the Current Procedural Terminology (CPT). The CPT is a code system set to

be used to report medical, surgical and diagnostic procedures and other services to entities that

include physicians, accreditation organizations, and health plans. The American Medical 5

Association is the trusted sources for official Current Procedural Terminology (CPT). 6

Clinical Domain

In the clinical domain, problem lists, allergies, personal medical history and family

medical history is a good practice to capture clinical information at the point of care using the

SNOMED-CT. According to Browman, “SNOMED-CT is a comprehensive, multilingual,

controlled clinical reference terminology, or common reference terminology, with

comprehensive coverage of diseases, clinical findings, etiologies, procedures, living organisms,

and outcomes used for recording clinical data. SNOMED-CT enables a consistent way of 7

capturing, sharing, and aggregating data across specialties and sites of care. It is designed for

use in electronic environments.

4 Medicaid.gov. ICD-10 Overview. Retrieved from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/icd-coding/icd.html 5 Rouse. M. SearchHealthIT. Current Procedural Terminology (CPT). Retrieved from http://searchhealthit.techtarget.com/definition/Current-Procedural-Terminology-CPT 6 American Medical Association. About CPT. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt.page? 7 Bowman, Sue. "Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems." Perspectives in Health Information Management Spring 2005 (May 25, 2005)

The Expected Benefits

The expected benefits of terminologies needs to be analyzed from the payer, provider and

patient perspective. SNOMED-CT helps the providers to have a better way to document clinical

interventions about the patient’s current and relevant conditions in the electronic health record

(EHR). It provides clear and consistent documentation, support them in collaborative care,

longitudinal patient records, and accurate patient data analysis. From the patient perspective, 8

withe personal health records, they will be able to access to their records in a way that can

understandable. RxNorm provide a clear way to represents the drugs in a way that corresponds

to the prescriber’s view, as an ingredient, strength and dose form. This help both patients and

providers to understand the medication lists. LOINC from a data sharing perspective it aids data

interoperability, improves analysis and reporting of the test results and clinical observations, and

links clinical and billing data. The integration of ICD-10 and CPT is key for health insurance to

classify and work medical billings accurately, fewers rejected claims, fewers fraudulent claims,

and better understanding of new procedures and better disease management. 9

8 Health Language Blog. How SNOMED CT Compliance Will Benefit Your Patients. January 28, 2015. Retrieved from http://blog.healthlanguage.com/how-snomed-ct-compliance-will-benefit-your-patients 9 AHIMA. What is the ICD-10-CM and ICD-10-PCS. Retrieved from http://www.ahima.org/topics/icd10/faqs