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American Public Health Association
133rd Annual Meeting & Exposition
December 10-14, 2005
Philadelphia, PA
APHA 2005
 
4024.0: Tuesday, December 13, 2005 - 8:45 AM

Abstract #115493

Standards For Coded Clinical Data Essential to the Electronic Health Record

Claire Dixon-Lee, PhD, RHIA, Vice President for Education, American Health Information Management Association, 233 N. Michigan Avenue - Suite 2150, CHicago, IL 60601, 312-233-1183, claire.dixon-lee@ahima.org

While the electronic health record (EHR) is the goal of the federal government through efforts toward a National Healthcare Information Infrastructure, and a goal of most healthcare organizations today, realization of its practical implementation and the universal need for clinical data standards remains a barrier to true interactive connectively across healthcare information systems. Within the US two primary nosology systems are felt to be the foundation of electronic data interchange to capture clinical information. They are SNOMED-CT and the commonly used ICD-9-CM systems. Efforts are being made on a national scale to move from ICD-9-CM to ICD-10 in tangent with international use of the tenth revision for morbidity and mortality reporting. Within the US, the ICD system is mired in controversy as the primary system for healthcare reimbursement. SNOMED-CT recently licensed through the National Library of Medicine, is considered to be fundamental to operational usefulness of electronic health records. This presentation introduces the clinical nosology systems most commonly used by healthcare organizations, how clinical data is codified, and the resulting impact on epidemiological studies that rely on clinical data access, completeness and accuracy.

Learning Objectives:

  • At the conclusion of this session, participants will be able to

    Keywords: Health Information Systems, Information System Integration

    Related Web page: www.ahima.org

    Presenting author's disclosure statement:

    I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.

    [ Recorded presentation ] Recorded presentation

    Epidemiologic Methods

    The 133rd Annual Meeting & Exposition (December 10-14, 2005) of APHA