select one of these aspects of the classification and representation of health i

Question

select one of these aspects of the classification and representation of health information (i.e., ad hoc representation, standard representation, informal standard, or formal standard)

1. In the first line of your posting, identify which aspect of the classification and representation of health information (ad hoc representation, standard representation, informal standard, or formal standard) you selected to research.

2. Describe two specific examples of this aspect of the classification and representation of health information that you were able to identify through your literature review. In what health care context(s) or setting(s) is it used? Why is it appropriate for use in these particular context(s) or setting(s)? Explain your reasoning.

3. Would any of the other aspects of the classification and representation of health information also be appropriate for use within these health care context(s) or setting(s)? If so, why? If not, why not? Explain your reasoning.

Explanation / Answer

One of the greatest technological challenges in health care today is the coordination and exchange of the vast amount of information generated by providers and organizations for their patients. To facilitate information system interoperability and data interchange, health information must be represented in a standardized form.

It's almost inescapable if we want to do quality improvement, outcomes research, best practice understanding, best evidence generation-- jargon phrases that are used widely in health care. But if we want to really do any of those effectively, efficiently, intelligently, and arguably, reproducibly, if we want to turn it into science, then we have to have standardized representation of the information.

There are a number of important terms that characterize this area of information, health information, really. Those set of words that we use really fall under the categorization of terminologies, collections of terms that we use to describe patients, to describe medical procedures, to describe laboratory tests, to describe drugs. All of those sorts of sets of words that we use to describe those fall under the notion of a terminology. When we take those terms and we divide those words, terms, descriptors into specific categories, such as disease states, or as an age category, or gender classification, or racial classification, those are considered to be classification systems because we're taking a patient or a characteristic of that patient, and putting it into a particular bucket, if you will, or a class, that describes that particular patient.

The characteristic of a classification is that you can only be in one class at a time. So the term that often describes that is mutually exclusive classifications. In other words, well, the simplest one I suppose is, one is alive or one is dead. There's really no intermediate state to describe a particular patient in that regard. What we find is that it's helpful to have agreed upon classifications, agreed upon terms, agreed upon nomenclatures, that we use in common across multiple settings. When we have those types of agreed upon sets of descriptors, sets of terms, then that comes under the notion of a standard.

A standard, in that case, focuses on, basically, this is a standard description, this is the description that we have agreed upon for this particular disease, or this is the set of classifications that everybody agrees we're going to describe gender, as a way of doing that. When we get into thinking about those terms and then think about the way we think about the organization of terms, we move up to another level of description information. And that goes by the description of an ontology.

An ontology is a organized set of terms, where those terms, each of the terms is defined, and the relationship between those terms are defined as well. So a simple example of an ontology might be a representation of the human body. The human body is the primary term in the ontology. And we also have associated with the human body, we have the appendages. We have heads, arms, legs, eyes, nose, mouth, et cetera. Those are all described as parts of the human body. And each of those, again, is classified as either left or right, et cetera. And so that sort of gives you the notion of what an ontology, how an ontology is described, how it's represented, and how it relates the terms, such as legs and arms, to the higher level concept the human body. That's a very simple exemplification of that. In human communications, we use words. But when you get to the point of starting to use information technology, using computers to represent that kinds of information, typically we go from simple words that we can use as human beings to a numeric, or alpha-numeric, codes.

A numeric code being something like 123.79, or an alpha-numeric code, something like A27-3, as examples of the different types of, examples of codes. Those codes are very important because information systems have to work with codes. They cannot work with words in their meetings. They can only work with those numeric or alpha-numeric codes representing the words that we use in the clinical care. The notion of representing clinical information, information about the patient. Whether it's a particular disease that they might have or one other physiological characteristics, or even a mental state that they might have, we tend, as professionals, to develop ways of describing those and classifying those states. That's diagnosis, disease, are examples of sets of classifications. But what typically has happened is that-- in medicine it's often described as more an art than a science at this point. And so you have small groups of professionals, let's say an ophthalmologist, develops one way of describing the characteristics of a patient, in terms of let's say age categories. And you also have pediatricians, those physicians who take care of young children. They have a much different way of thinking about age because, for a pediatrician, it's important to know how many months old the child is. But for an ophthalmologist, generally, they're much less concerned about the young children, and more about the broad age categories. So is somebody a child, are they an adult, are they a senior in an aging population? Those are examples of, if you will, an ad hoc classifications. And we are not denigrating that notion by describing it as ad hoc.

But it's a group of classifications, in some ways, it's an agreed upon set of classifications within a particular area that serves a particular purpose, serves a purpose for those groups of professionals. But when you try to bring that information together in an information system, really related to health, and representing all that information, you find that you have two different classifications for the same underlying information about age. And so we need to move from those ad hoc classifications to a standard classification of age, which can represent the information important to both the ophthalmologist and the pediatricians in the same database, if you will, same information system.

So that's when we really try to adapt standards for representing something like age, age categories. When we talk about informal versus formal. Formal standards are those where, typically, they have gone through a process of extensive reviews by a variety of parties who are interested in using that information, and some sense, officially approved. And that approval can vary considerably. It might be the approval of a professional organization, up to it might be approval of the federal government, or even to international organizations, such as the World Health Organization, in fact has established some formal standards. But what defines the formality of a standard is basically the approval and review process that goes into agreeing that this particular set of codes, or set of terms, is a standard. But before you have the those formal standards, typically you have the evolution of informal standards.

And this will happen, for instance, within let's say nurses, the nursing profession, or maybe even within a specific group of nurses, like public health nurses, who have a set of tasks that they need to accomplish, such as immunizations, would be one example, or dealing with other public health issues. And they develop a way of classifying those immunizations. It's important for their work. It might be whether somebody has received an immunization for a disease like pertussis, it could be something like annual flu shots, it could be a variety of different kinds of immunizations. They develop a classification system for that. It might be as simple as A, B, C, D, as a classification representing those. But when they share those among different groups of public health nurses, and those nurses all agree that code A represents a flu shot, and code B represents a diphtheria immunization, that's an example of an informal standards, where the professionals who are working in the area simply have agreed this is they way we're going to represent this information.

what Typically happens then at some point is you have another group of professionals who is representing the same information in a different sense. And so the formal standardization process really tries to bring those ad hoc representations together, and reach a common agreement on what A means, what B means, what C means, across the different groups. So then that agreement process results in a formal standard.

The federal government is a very good example of a formal standard. The Health Insurance Portability and Accountability Act, or often called HIPAA, has a set of electronic transactions standards. Those are formal standards. They are formal because there was a bill that was passed, and regulation written around that bill, that said, if you're going to submit electronic claims for purposes of payment to Medicare and other health insurers, you need to use a certain thing. And so it's a 3 formalized standard. And we're going to talk about a number of different of those standards, and specifically as it relates to HIPAA, there's code set standards. So it's a formal standard that says, if I want to submit, if I'm a physician, and I want to submit a bill to Medicare to get paid for my services. In order to do that, I need to submit it in a standardized way, that standard, in a code set, and that code set is ICD-9-CM for diagnoses, for example. It would be the current procedural terminology, or CPT, for my services and procedures. And I if I choose not to report that using those code set standards, I won't get paid by Medicare. So it's formal. It's very specific. It basically says, in order for things to happen, you must use these standards.

People often say, well, why we have these. Why can't we just have formal standards, because those are the things that everybody understands, must use, it's required, all those kinds of things? If there isn't a standard then maybe I don't want to do that type of thing. Well, it's very important to utilize a formal standard because you might need to be able to start to collect something. A good example would be in the area a problem lists. Physicians create, on a regular basis, a series, or a list, if you will, of problems that are going on in patients. So the patient comes to their office that day, they might have chronic conditions, and they might have a very specific acute condition that day. So they want to be able to not only look at the acute condition that they might present with, but they might also want to take into account the chronic conditions the patient has as well. So there's a running problem list. It could be something like, today they're here for the flu, but they also have congestive heart failure, they also have hypertension.

Well the fact that they had these chronic conditions in conjunction with the flu is very key to that doctor's treatment and how they're going to determine what the best care would be for them, versus just somebody walking in with the flu only. So they have this running problem list. In this problem list, they encode using terminology and classifications and code sets. Now there is no standard out there right now for a problem list. There are recommendations for people to use to encode a problem list. There are basically two out there.

There's one, SNOMED CT, that's being recommended as a way to capture data on a problem list and encode it. And there is ICD-9-CM. Both of those systems can identify a diagnosis. So it's like, well, we don't have a formal standard. We have two ways to represent this diagnosis. Is that good, is that bad? Well that's good, because at least we're starting to collect the information. Maybe before even considering that a standard exists or doesn't exist, we have a way to collect it. And collection is important if we're going to be able to analyze it, to do research on it, think about outcomes in terms of that patient care. All of that is very key. So you want to be able to collect it, even if you're collecting it one way, and I'm collecting it another. So you might collected the SNOMED CT, I might collect it in ICD-9, because there is no formal standard. It's a de facto standard. Now we're going to transition to a formal standard in conjunction with problem lists, because there's a lot of discussion in terms of electronic health records and interoperability. And the issue behind that is to make sure that we can talk the same language, are using the same terminology to encode something. So we're transitioning from a de facto standard in problem lists to a formalized, or formal, standard.

The way that our society, and the way that we see the federal government moving, and actually all the health care organizations, and the desire to be able to exchange information among organizations, we're moving away from the ad hoc standards and more toward the formal standards.

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