Access, availability and security of health information in health institutions are of paramount importance. Therefore health institutions have the responsibility of developing systems that will facilitate appropriate use, convenient access and security of health data. There are various concepts relating to health information technology which include classification standards, standards for electronic data interchange, and health record content and functional standards. As such, there are organizations in the USA that have significant on the adoption of healthcare information standards. The government has also passed various legislations and initiatives geared towards regulating health information standards. Therefore, the security, accessibility and the availability of accurate health information records influence the quality of health care considerably.
Classification Standards
Classification standards in health information refer to standards that govern the organization of medical terms into categories for easy identification. Moreover, different healthcare classification standards are normally used in varying healthcare settings. There are various reasons that make it necessary to categorize medical terminology. The reasons include: establishing a uniform and standard system to effectively facilitate healthcare reimbursement in the US, indexing of treatment outcome data, collecting, determining, collecting and reporting statistical data (Kaushal et al, 2003). Moreover, health care classification standards assist in the maintenance of database for administrative, demographic, clinical, and statistical data. Finally healthcare classification standards help in monitoring non-compliance as well as supporting quality and performance endeavors.
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The first health information classification standard was the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). The original classification standard was developed by the World Health Organization in Geneva, Switzerland. The health information classification standard was developed with an objective of collecting statistical data on morbidity and mortality rates and revised every ten years since 1948. The classification standard was adopted by the Veterans Administration and the United States Public Health Services for hospital indexing in 1950. Thereafter, the Columbia Presbyterian Medical Centre adopted the standard with some modifications for use in the medical records department. Also, the Commission on Professional and Hospital Activities in Michigan adopted the standard with some modifications to be used in the hospitals participating in the professional activity study.
The classification has evolved over years with modifications being done to make it suitable for the increasing demands in the healthcare sector health information. The United States National committee on Vital and Health Statistics, The American Hospital Association and the American Association of Medical Record Librarians reviewed the classification standard in terms of its efficiency for diagnostic indexing in 1956 with an objective of using the system to facilitate hospital indexing. The revision was issued in 1962, under the Classification of Operations and Treatments. However, there were challenges in most hospitals regarding the efficiency of the previous versions of the International Classification of Diseases until ICD-9-CM was finally developed. Currently, the ICD-9-CM health information classification standard is used to classify hospital inpatient procedures only whereas outpatient procedure are currently classified using the Current Procedural Terminology (CPT).
However, there are various issues surrounding the use of ICD-9-CM. it is argued that it is outdated and as a result, it diminishes the value of data which is always costly to gather hence pulling the US behind in terms of international progress. Uncoordinated release of the versions of the classification standard along with poor compliance to guidelines makes the ICD-9-CM ineffective.
Vocabulary and Terminology Standards
Vocabulary and terminology standards are essential for facilitating continuity of quality patient care. The standard medical terminologies are important in creating uniformity that enhances efficient collection of statistical data. A standard language that facilitates effective communication of healthcare information is vital in today’s constantly changing medical environment (Stead & Hammond, 1988). Terminology standards are classified into nomenclatures which are systematic listings of the proper names. They include Standardized Nomenclature of Disease and Systemized Nomenclature of Medicine.
The Standardized Nomenclature of Disease was developed by a group of German anatomists called Anatomical Society in1895. In 1965, the American College of Pathologists developed the Systemized Nomenclature of Pathology. The Systemized Nomenclature of Medicine was developed based on the Systemized Nomenclature of Pathology in 1974 by Dr. Roger Cote for use by various other healthcare settings. The Systemized Nomenclature of Medicine was converted to electronic media medical information systems, further expanding its use to other healthcare professionals apart from the physicians. As such, the terminology standards have undergone considerable changes. In 2002, the American College of Pathologists developed the Systemized Nomenclature of Medicine Computer Science (SNOMED CT) to reflect advances in medical informatics and computer science in healthcare. Recently, the SNOMED CT made the transition to the International Health Terminology Standards Development Organization (IHTSDO) in order to accelerate use and learning as well as linkages to international classification systems.
However, various issues related to effective and coordinated governance regarding the participating organizations. The government should ensure that open business by the all participating organizations is ensured to facilitate sustainability. Fragmented governance and uncoordinated release cycles may affect the success of the developments.
Standards for Electronic Data Interchange
Electronic Data Interchange refers to a standard format used to transmit health data. The standards are developed by the American National Standards Institute. There are various Electronic Data Interchange standards that include Continuity of Care Document Specification, and Continuity of Care Record. The Continuity of Care Document (CCD) specification is a standard intended to specify the structure, encoding, and semantics of a patient summary clinical document (Samuel et al, 2013). The United States Healthcare Information Technology Standards Panel selected the CCD as one of its Standards for electronic data interchange in health care. The Continuity of Care Record (CCR) is another standard recommended by the United States Health Care Information Standards panel for use in healthcare. The CCR creates flexible records that contain the timeliest and most relevant vital health information about a patient. The standards are developed progressively by vendor depending on need.
There are issues relating to electronic data interchange standards in terms of balanced involvement of partners. The lines between standards and proprietary have not been effectively defined leading to conflicts. As such, the government should establish strict regulations to curb the rise of proprietary interests.
Adoption and Use of Healthcare Information Standards
The US government has made considerable efforts in terms of promoting adoption and use of healthcare information standards (Richard, 2013). The US Health and Human Services Department has used its regulatory authority pursuant to Health and Information Technology for Economic and Clinical Health Act (HITECH), to enhance the protections afforded to individually identifiable health information in health care facilities. Moreover, the Health Insurance and Portability Act of 1996 (HIPAA), significantly limits the disclosure and use of identifiable health information available at most health care providers in the US. Therefore, the HIPAA act requires that healthcare providers should have technical, administrative, and physical safeguards regarding electronic identifiable information. Such protections from the law ensure that healthcare information is secure and available.
The government has also facilitated Electronic Health Records incentive programs through HITECH to encourage health care providers to conduct regular review and risk analyses in line with the HIPAA Security Rule. Moreover, several federal and state privacy laws prohibit the disclosure of sensitive and confidential health data as well as those pertaining to behavioral health such as HIV status, reproductive rights, adolescent treatment and genetic tests among others. Furthermore, the Human and Health Services department has encouraged the developers of Electronic Health Record systems to integrate security into their products to facilitate patient information safety. This involves encrypting electronic information, authenticating users of the HER technology, limiting access to data, and producing audit report.
This therefore, shows the commitment of the government in encouraging adoption and use of Health care information standards through legislations and programs. The development of the HITECH helped in promoting development and use of current methods in health care information handling.
Conclusion
Adoption and effective use of health care information standards among healthcare providers improves the quality of patient care. Therefore, health care providers should utilize current health care information systems to ensure safety and availability of health information. Moreover, the health care information standards evolve depending on need and the current technology. It is important to realize that the government has facilitated adoption and use of healthcare information standards.
References
Apsden, P., (2004). Patient Safety: Achieving a New Standard for Care. Washington: New Academies Press.
Statement of Richard J. Gilfillan, MD, Director, Centre for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services on Reform of the Delivery System, Before the Committee on Finance, U.S. Senate, March 20, 2013
Kaushal, R., Shojania, K., Bates, D., Effects of Computerized Physician Order Entry and Clinical Support Systems on Medication Safety: A Systematic Review. Arch International Medicine, (2003), I409-1416
Samuel, C., King, J., Adetosoye, F., Sammy, L., Furukawa, M., Engaging Providers in Underserved Areas to Adopt Electronic Health Records. American Journal of Managed Care, (2013); 19(3): 229-235
Stead, W., Hammond, W., “Computer-based Medical Records: The Centerpiece of TMR,” M.D Computing, 5 (1988), 48-62
