TIGER STANDARDS & INTEROPERABILITY WORKGROUP 1: Catalogue and develop an inventory of the most rele Framing Statement: Interoperable systems are critical in order to assist clinicians in delivering sa and patient-centered care. Clinical data standards are the essential building blocks towards intero including Electronic Health Records (EHRs), Electronic Medical Records (EMRs), and Personal He standards and their impact on care delivery. Definitions Standard - A definition or format that has been approved by a recognized standards organization or is accepted as a de facto s formats, communications protocols, and electrical interfaces. HIMSS Dictionary of HIT Terms 2006 A standard specifies a well-defined approach that supports a business process and: (1) has been agreed upon by a group of e to ensure that materials, products, processes, and services are fit for their intended purpose; (5) is available in an accessible fo Standards mean the structure and content of health care data, information, or concepts that are usefully exchanged or provide methods used to facilitate these exchanges. Dr. John Halamka, Chair of the Health Information Tech that for HITSP work Interoperability - The ability of two or more systems or components to exchange information and to use the information that ha IEEE Dictionary Interoperability means the ability of different information systems, software applications and networks to communicate and ex The current landscape of standards does not ensure interoperability due to many factors, such as conflicts and gaps. Further, f standards that do not traditionally fall into the commonly accepted health care standards arena (e.g., broader technology standa Harmonization means the function of developing, reconciling, setting and maintaining standards required to achieve interoperab Department of Health and Human Services (HH Workgroup Members First Name Last Name Email Business Phone Ginny Meadows firstname.lastname@example.org 770-319-7295 Carlene Anteau email@example.com Melita Howell firstname.lastname@example.org 832-824-4434 Cyndie Lundberg email@example.com 1-847-832-7673 Myrna Mamaril firstname.lastname@example.org 720-848-0951 Carol Petersen email@example.com Virginia Saba firstname.lastname@example.org 703-521-6132 Kathleen Smith email@example.com 301-869-7428 Anna Poker firstname.lastname@example.org 301-299-6778 TIGER Support Team Donna DuLong email@example.com 303-333-3246 Elizabeth Halley firstname.lastname@example.org 703-983-1076 Joyce Sensmeier email@example.com 312-915-9281 Pat Walker firstname.lastname@example.org (240) 426-8268 NDARDS & INTEROPERABILITY COLLABORATIVE op an inventory of the most relevant health IT standard setting efforts and resources ssist clinicians in delivering safe, effective, efficient building blocks towards interoperable systems, cords (EMRs), and Personal Health Records (PHRs). It is important that nurses understand these Definitions ganization or is accepted as a de facto standard by the industry. Standards exist for programming languages, operating systems, data Dictionary of HIT Terms 2006 ) has been agreed upon by a group of experts; (2) has been publicly vetted; (3) provides rules, guidelines, or characteristics; (4) helps pose; (5) is available in an accessible format; and (6) is subject to an ongoing review and revision process. s that are usefully exchanged or provided between and among care providers and public health authorities, and the interchange mka, Chair of the Health Information Technology Standards Panel (HITSP), explained to the American Health Information Community mation and to use the information that has been exchanged. ictionary ns and networks to communicate and exchange information in an accurate, effective, useful, and consistent manner. s, such as conflicts and gaps. Further, for true interoperability to be realized, many standards need to be harmonized, including s arena (e.g., broader technology standards for data interchange). tandards required to achieve interoperability. ment of Health and Human Services (HHS) Office of the National Coordinator for Health IT (ONC) ers Organization Standard Type Standards Initiatives, Standards Shared Health, Inc: Workgroup 1 Organizations, Leader Documentation McKesson None No longer Texas Children's Hospital participating Terminology, SNOMED Terminology Solutions Documentation ASPAN Documentation AORN None CCC Terminology Data Exchange/ ICCE, L.L.C. Messaging Infrastructure TIGER Initiative The MITRE Corporation HIMSS Uniformed Services University of Health Sciences, School of Nursing tand these perating systems, data aracteristics; (4) helps the interchange ormation Community nner. nized, including Types of Standards Standard Type Definition Data These standards allow transactions to flow consistently between systems, Exchange/Messaging as they contain specifications for format, data elements, and structure Terminology Standards These vocabularies provide specfic codes for clinical concepts such as diseases, problem lists, allergies, medications, and diagnosis that might have varying textual descriptions in a paper chart or a transcription. Examples of terminologies would include LOINC for lab results, SNOMED CT for clinical terms, and ICD for medical diagnoses. Standards Initiatives What are the key standards initiatives in healthcare information technology today? Standards What organizations are involved in creating different standards used in Development healthcare information technology? This section will provide an overview of Organizations all of those organizations, and the standards they are responsible for. Document Standards These indicate what type of information is included in a document and where it can be found. A common standard in paper medical records is the SOAP format (Subjective, Objective, Assement, Plan) The CCR (Continuity of Care Record) provides a standard format for inter-provider communication, Infrastructure The overall framework or architecture used. This would include an Standards information model. Gap Identified - Usability/UI Standards (There are no standards defined for this area) Examples HL7 DICOM IHE IEEE CORE LOINC SNOMED CT ICD CPT HITSP CCHIT HL7 ANSI AMA CDA/CCR Braden Scale Pain Assessment SOAP caCORE NHIN PHIN Date Exchange/Messaging Standard Type Standard Acronym Description Developer/Standard Accredited ASC X12 Standards to facilitate electronic interchange http://www.disa.org/x12o Standards relating to order processing, shipping, rg/index.cfm Committee X 12 receiving, invoicing, payment insurance transactions, etc. related to the provision of products and services. Clinical Data CDISC Format for reporting data collected in clinical Clinical Data Interchange trials Interchange Standards Standards Consortium Consortium www.cdisc.org Common Object CORBA Develops object oriented interoperability http://www.omg.org/getti Request Broker standards. ngstarted/corbafaq.htm Architecture. CORBA CORBA Aims to improve adaptability and simplify the Component Model CCM task of writing distributed applications. Digital Imaging and DICOM Format for communicating radiology images National Electronics Communications in and data Manufacturers Medicine Association Committee www.nema.org Health Level 7 HL7 V2.x Electronic Message Formats for Clinical, Health Level Seven Messaging HL7 V3 Financial and Administrative Data. "Level www.hl7.org Standards, Version Seven" refers to the highest level of the 2 and Version 3 International Organization for Standardization (ISO) communications model for Open Systems Interconnection (OSI) - the application level. The application level addresses definition of the data to be exchanged, the timing of the interchange, and the communication of certain errors to the Institute of IEE MEDIX Standard for the exchange of data between http://aspe.hhs.gov/adm electrical and hospital computer systems. nsimp/hisbinvb.htm Electronic Engineers P1157 Medical Data Interchange Standard Integrating the IHE IHE Profiles organize and leverage the Integrating the Healthcare integration capabilities that can be achieved by Healthcare Enterprise Enterprise coordinated implementation of communication www.ihe.net standards, such as DICOM, HL7 W3C and security standards. They provide precise definitions of how standards can be implemented to meet specific clinical needs. NCPDP SCRIPT NCPDP NCPDP creates and promotes standards for National Council for standard for the transfer of data to and from the pharmacy Prescription Drug ePrescribing services sector of the healthcare industry. The Programs (Version 10.0 organization provides a forum and support wherein our diverse membership can efficiently and effectively develop and maintain these standards through a consensus building process. NCPDP also offers its members resources, including educational opportunities and database services, to better manage their businesses. ssaging Standard Type Additional Contact SME (Subject Matter Experts) Resources Don Bechtel Foundation Enterprise Systems Standards and Regulatory Compliance Chief Privacy Officer, HDX 65 Valley Stream Parkway, Malvern, PA, 19355-1406 Phone: +01 610 219 1695 Fax: +01 610 219 1655 E-Mail: Donald.Bechtel@siemens .com Rebecca Kush President & CEO Phone: 512-327-0738 Fax: 512-327-0517 Cell: 512-791-7612 Email: email@example.com Telephone: +1-781-444- 0404 Fax: +1-781-444-0320 Email: firstname.lastname@example.org email@example.com Howard E. Clark, Ph.D. http://medical.n DICOM Secretariat ema.org/dicom/ National Electrical http://medical.n Manufacturers ema.org/dicom/ Mark McDougall Linda Fischetti RN MS, U.S. Department Executive Director of Veterans Affairs, Phone: 301-734-0417 Health Level Seven Email: firstname.lastname@example.org, Term 3300 Washtenaw Expires on: 31-Dec-2009 Avenue, Suite 227 Ann Arbor, MI 48104- 4261 Phone: (734) 677-7777 Fax: (734) 677-6622 Email: Phone: +1 800 701 IEEE (USA and Canada) +1 732 981 0060 (Worldwide) Fax: +1 732 981 9667 http://www.ieee.org/web/a boutus/help/feedback.htm l Joyce Sensmeier VP, Didi Davis Director, IHE, HIMSS Informatics, HIMSS email@example.com Audrey Dickerson , firstname.lastname@example.org Manager, Standards, HIMSS email@example.com See Standards www.ncpdp.org Development Organizations Terminology Standard Type Standard Acronym Description Definition: Interface vs. Reference Terminology In simple terms, an interface terminology, commonly called point-of-care terminology, is one that is used by clinicians to record that comparisons can be made even when different terminologies are used. Terminology used at the point-of-care is encoded b nursing diagnosis from the North American Nursing Diagnosis Association International (NANDA I) (point-of-care terminology) c REFERENCE TERMINOLOGIES Systemized Nomenclature of SNOMED CT SNOMED Clinical Terms (SNOMED CT) is a dynamic, Medicine - Clinical Terms V3 / IHTSDO scientifically validated clinical health care terminology and infrastructure that makes health care knowledge more usable and accessible. It provides a common language that enables a consistent way of capturing, sharing and aggregating health data across specialties and sites of care. SNOMED CT is comprised of concepts, terms, and relationships used to define concepts precisely that represents clinical information. SNOMED CT consists of hierarchies, e.g.: clinical findings, procedures, observable entity, and pharmaceutical/biological product,etc. SNOMED CT combines the content and structure of the SNOMED Reference Terminology (SNOMED RT) with the United Kingdom’s Clinical Terms Version 3 (formerly known as the Read Codes). The following American Nurses Association recognized nursing classifications are integrated within SNOMED CT include the Clinical Care Classification, NANDA I, Nursing Interventions Classification, Nursing Outcomes Classification, Omaha System, and Perioperopative Nursing Data Set. Logical Observation Identifiers LOINC (LAB) The purpose of LOINC is to facilitate the exchange Names and Codes - Laboratory 2.22, and pooling of clinical results for clinical care, RELMA 3.23 outcomes management and research by providing a Regenstrief set of universal codes and names to identify laboratory Loinc and other clinical observations. Mapping Assistant Web-based Logical Observation Identifiers LOINC The clinical portion of the LOINC database includes Names and Codes- Clinical (Clinical) entries for vital signs, hemodynamics, intake/output, 2.22, EKG, obstetric ultrasound, cardiac echo, urologic RELMA 3.23 imaging, gastroendoscopic procedures, pulmonary Regenstrief ventilator management, selected survey instruments, Loinc and other clinical observations. Mapping Assistant Web-based International Classification of ICNP The ICNP® is a unified nursing language system. It is Nursing Practice (ICNP) Version 1.0 a compositional terminology for nursing practice that facilitates the development of and the cross-mapping among local terms and existing terminologies.The ICNP data elements consist of 1) nursing phenonomen, 2) nursing actions, and 3) nursing outcomes. STANDARDIZED NURSING CLASSIFICATIONS SYSTEMS ABC Coding Manual for Integrative ABC codes ABC codes were designed to fill gaps in existing code Healthcare (ABC) 1st Release sets to support compl;iance with Health Insurance Portability and Accountability Act of 1996 (HIPAA). ABC codes are part of a comprehensive coding system that supports research., management, and commerce in the fields of alternative medicine, nursing and other forms if integrative healthcare. All related coding processes and systems , including the five - character alphabetic ABC codes, two-character practitioner identifiers, terminology, product and service descriptions, expanded definitions practitioner- specific tools (such as scope of practice, relative value units, decision support and training standards to different practitioner types) and other materials are the intellectual property of Alternative Link, Inc. or its affiliates Relative Value Studies, Inc. Clinical Care Classification System CCC system CCC System is a standardized terminology of (CCC) Version 2.0 concepts/terms for the electronic documentation of patient care primarily by nurses in all healthcare settings enabling ongoing analysis and generation of evidence-based care guidelines. The system consists of two interrelated terminologies: CCC of Nursing Diagnoses and Outcomes and CCC of Nursing Interventions and Actions, which are organized into a single system categorized by Care Components representing the functional, physiological, psychological, and health behavioral patterns of care. CCC links diagnoses, interventions and outcomes to each other and enables them to be mapped to other health-related terminologies such as SNOMED CT. CCC is used to track and measure patient/client care holistically over time, across settings, population groups, and geographic locations. North American Nursing Diagnosis NANDA I NANDA International is a member driven, grassroots Association International (NANDA) organization committed to the development of nursing 2007-2008 diagnostic terminology. The desired outcome of the Association's work is to provide nurses at all levels and in all areas of practice with a standardized nursing terminology with which to: - client responses to actual or potential health problems, life processes, and wellness; - care for reimbursement of nursing services; - contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health care records; and facilitate study of the phenomena of concern to nurses for the purpose of improving patient care. Nursing Interventions Classification NIC The Nursing Interventions Classification (NIC) is a (NIC) 5th Edition comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties. NIC interventions include both the physiological (e.g. Acid-Base Management) and the psychosocial (e.g. Anxiety Reduction). There are interventions for illness treatment (e.g. Hyperglycemia Management), illness prevention (e.g. Fall Prevention), and health promotion (e.g. Exercise Promotion). Interventions are for individuals or for families (e.g. Family Integrity Promotion). Indirect care interventions (e.g. Emergency Cart Checking) and some interventions for communities (e.g. Environmental Management: Community) are also included. NIC consists of 542 Interventions, all domains, classes, and interventions have definitions, and the four level taxonomy structure is coded. NIC has a system in place for regular updates. Nursing Minimum Data Set (NMDS) NMDS Minimum set of items of information with uniform definitions and categories concerning the specific dimension of professional nursing, which meets the information needs of multiple data users in the health care system. Nursing minimum data set consists of nursing diagnosis, nursing intervention, nursing outcome, intensity of nursing care. Nursing Management Minimum Data NMMDS Data variables categorized into environment, nurse Set (NMMDS) resources, and financial resources that are needed to inform the decision making process of nurse executives related to leading and managing nursing services delivery and care coordination. Nursing Outcome Classification 4th NOC The Nursing Outcomes Classification (NOC) is a Edition comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses. An outcome is a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions. The outcomes are developed for use in all settings and with all patient populations. Clinical sites used to test the NOC included tertiary care hospitals, community hospitals, community agencies, nursing centers, and a nursing home. The outcomes are developed for use in all settings and can be used across the care continuum to follow patient outcomes throughout an illness episode or over an extended period of care. Since the outcomes describe patient/client status, other disciplines may find them useful for the evaluation of their interventions. Omaha System 2005 Edition N/A The Omaha System is a research-based, comprehensive and standardized taxonomy designed to enhance practice, documentation, and information management. It provides the framework and terms for diverse EHRs. It consists of an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes). Multidisciplinary health care practitioners in any setting use the terms, definitions, and codes from the time they admit individuals, families, and communities to service until discharge. The Omaha System provides a structure to document client needs and strengths, describe care plans and services, and measure client outcomes in a simple, yet comprehensive, manner. Perioperative Nursing Data Set PNDS The Perioperative Nursing Data Set (PNDS) is a (PNDS) Version 2 standardized nursing vocabulary that addresses the perioperative patient experience from pre-admission until discharge. As a nursing language, PNDS is parsimonious, validated, reliable, and useful for clinical practice. The PNDS can serve many purposes, depending on the audience and user. A few examples of these potential uses include: --Providing a framework to standardize documentation --Providing a universal language for perioperative nursing practice and education --Assisting in the measurement and evaluation of patient care outcomes --Providing a foundation for perioperative nursing research and evaluation of patient outcomes --Informing decisions about the relationship of staffing to patient outcomes --Providing data about the contributions of nurses to patient outcomes in the perioperative arena International Classification of (ICD-9-CM) The ICD-9-CM id published by the US Government in Diseases- Ninth Revision – Clinical recognition of its responsibility to promulgate this Modification classification throughout the United States for morbidity coding . The ICD-9 Revision published by the World Health Organization (WHO) is the foundation of the ICD-9-CM and continues to be the classification employed in the cause-of-death coding in the United States. The ICD-9-CM is completely compatible with the ICD-9. The WHO Center for Classification of Diseases for North America serves as Liaison between the international obligations of comparable classifications and the national health data needs of the United States. The ICD-9-CM is recommended for use in all clinical settings but is required for reporting diagnoses and diseases to all U.S. Public Health Service and Health Care Financing Administration (now Center for Medicare and Medicaid Services (CMS) programs. Volume 3 is the CM and refers to procedures and operations. Reimbursed by the federal government. International Statistical ICD-10 The International Classification of Diseases is Classification of Diseases and published by the World Health Organization. The ICD Related Health Problems- Tenth is used world-wide for morbidity and mortality Revision (ICD-10) statistics, reimbursement systems and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is a core classification of the WHO Family of International Classifications (WHO-FIC). It provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ICD-10 is used world-wide for only Mortality Statistics. The world nations also use it for Morbidity Statistics except the Unites States which has not yet initiated it into their coding systems. The International Classification of ICF The ICF is WHO's framework for measuring health Functioning and Health (ICF) and disability at both individual and population levels. It acknowledges that every human being can experience a decrement in health and therheby experience some degree of disability. ICF 'mainstreams' the experience of disability and recognises it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric - the ruler of health and disability. Furthermore ICF takes into account the social aspects of disability and does not see disability only as 'medical' or 'biological' dysfunction. By including Contextual Factors, in which environmental factors are listed, ICF allows to record the impact of the environment on the person's functioning. Current Procedual Terminology CPT CPT® is Current Procedural Terminology, and was developed by the American Medical Association in 1966. Each year, an annual publication is prepared, that makes changes corresponding with significant updates in medical technology and practice. The American Medical Association, through its Department of CPT Editorial Research and Development, provides staff support to the process of adding, modifying, and deleting CPT codes. The 17-member CPT Editorial Panel meets 3 times a year and considers proposals for changes to CPT. RxNorm RxNorm RxNorm, a standardized nomenclature for clinical drugs, is produced by the National Library of Medicine (NLM). In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and form. RxNorm’s standard names for clinical drugs are connected to the varying names of drugs present in many different controlled vocabularies within the Unified Medical Language System (UMLS) Metathesaurus, including those in commercially available drug information sources. These connections are intended to facilitate interoperability among the computerized systems that record or process data dealing with clinical drugs. inology Standard Type Developer Contact SME (Subject Matter Standards Experts) Recognitions s used by clinicians to record data. A reference terminology is a set of terms to which the terminology in the point-of-care terminologies is ma he point-of-care is encoded behind the scenes so that data can be extracted and analyzed to improved patient care outcomes. For example, ) (point-of-care terminology) can be mapped to a “Clinical Finding” in SNOMED CT (Reference Terminology). ****FOR MORE INFORMATION PLEASE ACCESS EACH OF THE INDIVIDUAL WEBSITES**** International Health http://www.ihtsdo.org/ Cynthia B Lundberg RN, BSN Consolidated Health Terminology Standards www.capsts.org CAP - STS Phone: Informatics (CHI); Development Organization 1--847-832-7673 Healthcare Information (IHTSDO) And Technology Standards College of American Panel (HITSP) ; Pathologist - SNOMED American Nurses Terminology Solutions Association (ANA); American National Standards Institute (ANSI ) ; National Committee on Vital and Health Statistics (NCVHS) “Subcommittee on Standards and Safety” (United States) Kathy Mercer firstname.lastname@example.org Healthcare Information LOINC c/o Medical Technology Standards Informatics Panel (HITSP); The Regenstrief Institute, American Nurses Inc Association (ANA); 410 West 10th Street, National Committee on Suite 2000 Vital and Health Indianapolis, IN 46202- Statistics (NCVHS) 3012 “Subcommittee on Standards and Phone: 317-423-5558 Safety”(United States) Fax: 317-423-5695 IU campus mail address: HS, 2000 Susan Matney, MSN, RN email@example.com American Nurses Sr. Content Engineer Association (ANA); Office of the Associate VP National Committee on for Health Sciences Vital and Health Information Technology, Statistics (NCVHS) University of Utah “Subcommittee on 26 South 2000 East Standards and Safety” (HSEB suite 5725C) (United States) Salt Lake City, Utah 84112 Phone: 801 585-9871 Fax: 801 581-4297 Email: firstname.lastname@example.org International Council of http://www.icn.ch/icnp_r For Nursing Content: American Nurses Nursing eview.htm Amy Coenen, PhD, RN, Association (ANA) FAAN, Associate Professor Director, International Classification for Nursing Practice (ICNP®) International Council of Nurses University of Wisconsin - Milwaukee College of Nursing P.O. Box 413 Milwaukee, WI 53201-0413 Phone: 414 299-5146 Fax: 414 299-6474 E-mail: email@example.com Alternative Link, Inc. Or its www.ABCcodes.com American Nurses affiliates Relative Value Association (ANA); Studies, Inc National Committee on Albuquerque, NM 87110. Vital & Health Statistics ABC Coding Solution- (NCVHS) Alternative Link Subcommittee on Albuquerque, NM Standards and Security Tel: (505) 875-0001 Toll Free: 877-621-LINK Fax: 505-875-0002 Virginia K. Saba (EdD, www.sabacare.com Healthcare Information RN, FAAN, FACMI) and And Technology Standards Colleagues www.clinicalcareclassifi Panel (HITSP) ; CEO & President cation.com American Nurses Sabacare Inc. Association (ANA) Arlington, VA Distinguished Scholar, Adjunct Georgetown University Washington, DC NANDA International firstname.lastname@example.org American Nurses Diagnositic Development Association (ANA) Committee 100 N. 20th Street, 4th Floor Philadelphia, PA 19103 Protocol for Submission or Revision of Diagnoses found at http://www.nanda.org/html /nursing_diagnosis_devmt .html Editor: Gloria Bulechek, classification- American Nurses PhD, FAAN, Professor email@example.com Association (ANA) Phone: 319/335-7115 Email: gloria- firstname.lastname@example.org AND Howard K. Butcher, PhD, RN, APRN, BC AND Joanne McCloskey Dochterman, PhD, RN, FAAN Center for Nursing Classification & Clinical Effectiveness The University of Iowa, College of Nursing 407 NB Iowa City IA 52242-1121 319-335-7051 Fax: 319- 335-6820 Connie Delaney, PhD, RN, Diane Huber, PhD, RN, American Nurses FAAN, FACMI FAAN, CNAA Association (ANA) Co-PI, NMMDS NMMDS School of Nursing 1222 Oakes Drive 5-160 Weaver Densford Iowa City, IA 52245-0113 Hall Phone: 319-335-7122 The University of FAX: 319-354-0113 Minnesota 308 Harvard Street SE Minneapolis, MN 55455 Phone: 612-624-5959 Fax: 612-624-3174 E-mail: Delaney@umn.edu Connie Delaney, PhD, RN, diane- American Nurses FAAN email@example.com Association (ANA) Co-PI, NMMDS College of Nursing, University of Iowa Iowa City, IA 52242-1121 Phone: 319-335-7113 319-335-7122 319-335-7119 E-mail: Delaney@umn.edu Sue Moorhead Phone: classification- American Nurses 319/335-7110 firstname.lastname@example.org Association (ANA) Center for Nursing Classification & Clinical Effectiveness The University of Iowa, College of Nursing 407 NB Iowa City IA 52242-1121 319-335-7051 Fax: 319- 335-6820 Email: sue- email@example.com Karen S. Martin, RN, www.omahasystem.org Healthcare Information MSN, FAAN Technology Standards Martin Associates Panel (HITSP) ; 2115 S. 130th St. American Nurses Omaha, NE 68144 Association (ANA) Phone: 402-333-1962 Email: firstname.lastname@example.org Association of email@example.com American Nurses periOperative Registered Association (ANA) Nurses (AORN) 2170 South Parker Road, Suite 300 Denver, CO 80231 Toll Free: 800-755-2676 Local: 303-755-6304 Ext. 392 WHO Center for http://www.ICD9.chrise Classification of Diseased ndres.com for North America National Center for Health Statistics (NCHS) Public Health Service (PHS), Health & Human Services (HHS) World Health Organization http://www.who.int/class ifications/icd/en/ World Health Organization http://www.who.int/class ifications/icf/en/ American Medical http://www.ama- Association assn.org/ama/pub/cate gory/3113.html National Library of http://www.nlm.nih.gov/r Medicine esearch/umls/rxnorm/o 8600 Rockville Pike verview.html Bethesda, MD 20894 Other Resources oint-of-care terminologies is mapped so nt care outcomes. For example, a Leann Scroggins, MS, RN, CRRN-A, APRN, BC; Geralyn Meyer, PhD, RN; T. Heather Herdman, PhD, RN; Margaret Lunney, PhD, RN; Lynda Juall Moyet, RN, CRNP, MSN; Dorothy Jones, EdD, RN, FAAN; Marlene Lindeman, RN, MSN, CS; Sara E. Lister, MSN; Lina Rahal, BScN, MEd, RN;Barbara Vassallo, RN, MSN, EdD, CS, ANPC Johnson,M., Bulechek, G.M., Butcher, H., Dochterman, J.M., Maas, M., Moorhead, S. & Swanson, E. (2006). NANDA, NOC, and NIC linkages: Nursing Diagnoses, Outcomes and Interventions. (2cd Ed.) Philadelphia: Elsevier Inc. Standards Initiatives Standard Type What are the key standards initiatives in healthcare information technology today? Standard Initiatives Acronym Description Contact Agency for AHRQ AHRQ funds health information technology research Healthcare and development with $166 million in grants and Research and contracts. This money is awarded to programs Quality across the country to support and stimulate investment in health IT, especially in rural and underserved areas. AHRQ also created the National Resource Center for Health Information Technology, which provides technical assistance and shares knowledge and findings that have the potential to transform every day clinical practice. American Health AHIC The AHIC is a federal advisory body, chartered to Department of Health Information make recommendations to the Secretary of HHS on and Human Services - Community how to accelerate the development and adoption of Office of the National Health IT. The AHIC pursues breakthroughs that will Coordinator produce tangible value to the health care consumer in the near-term, while building toward long-term goals for a broad and robust system. Centers for CMS CMS sets the standards for many HIT Initiatives, for Medicare & example, HIPAA, the ePrescribing standards, etc. Medicaid Services CMS’s new Electronic Health Record (EHR) demonstration is designed to show that widespread adoption and use of interoperable EHRs will reduce medical errors and improve the quality of care for an estimated 3.6 million consumers. Over a five-year period, the project will provide financial incentives to as many as 1,200 physician practices that use certified EHRs to improve quality as measured by their performance on specific clinical quality measures. Additional bonus payments will be available, based on a standardized survey measuring the number of EHR functionalities a physician practice has incorporated. To further amplify the effect of this demonstration project, CMS is encouraging private and public payers to offer similar financial incentives consistent with applicable law. Certification CCHIT The Certification Commission is a recognized Sue Reber, CCHIT Commission for certification body for electronic health records and (503) 703-0813 Healthcare their networks, and a private, nonprofit initiative. firstname.lastname@example.org Information Their mission is to accelerate the adoption of health Technology information technology by creating an efficient, credible and sustainable certification program. Federal Adoption FAST Federal Adoption of Standards for health IT of Standards for (FAST) supports coordinated review, analysis, Health IT (FAST) architectural integration, and educational awareness of health interoperability standards. - The FAST initiative’s tasks include: - Interagency support and facilitation of federally managed standards communications - Cross-agency collaboration on various aspects of the standards lifecycle, including use case review, HITSP requirements, design and standards selection (RDSS) and interoperability specifications, and standards Federal Health FHA The Federal Health Architecture (FHA) was Architecture established as an eGov Line of Business in response to The President's Management Agenda calling for increased efficiency and effectiveness in government operations. The FHA is responsible for: - Leveraging federal expertise in creating a federal framework that would be derived from a national health IT infrastructure. - Supporting federal activities in the development and adoption of health IT standards. - Ensuring that federal agencies can seamlessly exchange health data between and among themselves, with state, local and tribal governments, and with private sector healthcare organizations. The Consolidated Health Informatics Initiative (CHI) has been a high-level, collaborative segment of the Federal Health Architecture (FHA) program tasked with establishing a portfolio of existing and commonly used clinical vocabularies and messaging standards for Federal partners. Health Resources HRSA The Health Resources and Services and Services Administration (HRSA), an agency of the U.S. Administration Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. HRSA oversees organ, tissue and blood cell (bone marrow and cord blood) donation and vaccine injury compensation programs, and maintains databases that protect against health care malpractice and health care waste, fraud and abuse. Healthcare HITSP Healthcare Information Technology Standards Panel American National Information serves as a cooperative partnership between the Standards Institute Technology public and private sectors for the purpose of Standards Panel achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States. National Alliance NAHIT Interagency support and facilitation of federally for Health managed standards communications Information Mission: Promote, influence, and support the Technology effective and efficient application of health IT for the purpose of achieving safe, high quality, affordable health care. NAHIT will accomplish its work in several defining ways: - By its role as a national convener/integrator of diverse organizations and thought leaders to explore and exchange innovative ideas, vet key issues and help achieve industry-wide consensus. - By identifying and disseminating evidence-based practices and proven strategies for the adoption and use of health IT, establishing a go-to and trusted source in health care. Approved May 22, 2008 - By concentrating on the engagement of C-level leaders, with particular emphasis on the necessary alignment of executive-clinical-technology decision- makers. National Institutes NIH Cross-agency collaboration on various of Health aspects of the standards lifecycle, including use case review, HITSP requirements, design and standards selection (RDSS) and interoperability specifications, and standards lifecycle education Nationwide Health NHIN The Nationwide Health Information Network (NHIN) Department of Health Information is the critical portion of the health IT agenda intended and Human Services - Network to provide a secure, nationwide, interoperable health Office of the National information infrastructure that will connect providers, Coordinator consumers, and others involved in supporting health and healthcare. Office of the ONC The Office of the National Coordinator for Health Office of the National National Information Technology provides leadership for the Coordinator for Health Coordinator development and implementation of a nationwide Information health IT infrastructure allowing secure and Technology, seamless exchange of data and records. The ONC Department of Health advises the Secretary of HHS on health IT policies and Human Services, and initiatives, and coordinates the Department’s 200 Independence efforts to meet the President’s goal of making an Ave. SW, Suite 729-D, electronic medical record available for most Washington, DC Americans by 2014. 20201, Telephone: 202-690-7151, Facsimile: 202-690- 6079, Email: email@example.com U.S. Department of DoD Currently, thousands of military medical providers Defense use the DoD’s electronic health record system, AHLTA, and nearly 300,000 outpatient visits are captured digitally every week. DoD’s vision is to provide each patient with a continuously updated digital medical record from the point of injury or care on the battlefield to discharge from military clinics and hospitals in the United States. These records would be completely transferable electronically to the Veterans Health Administration as part of the Joint Patient Electronic Health Record (JPEHR). U.S. Health USHIK The United States Health Information Information Knowledgebase (USHIK) is a health metadata Knowledgebase registry funded and directed by the Agency for Healthcare Research and Quality with management support in partnership with the Centers for Medicare & Medicaid Services. USHIK provides and maintains a metadata registry of health information data element definitions, values and information models that enable browsing, comparison, synchronization and harmonization within an uniform query and interface environment. It is populated with the data elements and information models of Standards Development Organizations (SDO) and other healthcare organizations, in such a way that public and private organizations can harmonize information formats with healthcare standards. It also contains data element information for government initiatives that support the use and implementation of data standards such as the Health Insurance Portability and Accountability Act (HIPAA) and the Consolidated Health Informatics (CHI) initiative. The U.S. Health Information Knowledgebase established a metadata registry methodology based on International Organization for Standardizations® (ISO®)/International Electrotechnical Commission™(IEC) 11179 Information technology - Specification and Standardization of Data Elements. Veterans Health VHA The VHA is a division of the U.S. Department of Administration Veteran’s Affairs, and provides care for over five million veterans of the United States Armed Services. The VHA’s electronic health record system, My HealtheVet, allows patients to refill prescriptions online, and provides access to health information, links to Federal and VA benefits and resources, and the patient’s Personal Health Journal. The VHA continues to add capabilities to My HealtheVet, to empower consumers to take a more active role in managing their health and health care. ype SME (Subject Website/ Other Matter Experts) Resources http://healthit.ahrq.gov http://www.hhs.gov/heal thit/community/backgro und/ www.cms.hhs.gov Information Technology general information: http://www.cms.hhs.gov /InfoTechGenInfo/ Alisa Ray, Executive www.cchit.org Director firstname.lastname@example.org www.hhs.gov/healthit/st andards/other/ http://www.hhs.gov/fedh ealtharch/ www,hrsa.gov HITSP Secretariat: www.hitsp.org Michelle Maas Deane mmaasdeane@ansi. org ; John Halamka, MD, HITSP Chair, ;jhalamka@caregrou p.harvard.edu; Joyce Sensmeier, Technical Manager, HITSP, jsensmeier@himss. org www.nahit.org www,nih.gov Office of www.nhin.com Interoperability and Standards http://www.hhs.gov/heal thit/onc/mission/ www.defenselink.mil www.va.gov/health/ Standards Development Organizations Standar Standard Organization Acronym Description Web Site Accredited Standards X12 In 1979, the American National www.x12.org Committee X12 Standards Institute (ANSI) chartered the Accredited Standards Committee (ASC) X12 to build and support electronic exchange standards, related documents, and products intended for worldwide use. American Dental ADA Code on Dental Procedures and www.ada.org Association Nomenclature (CDT): HIPAA standard used to code dental procedures for dental claims American Health AHIMA AHIMA is the premier association of www.ahima.org Information Management health information management (HIM) Association professionals. AHIMA's members are dedicated to the effective menagement of personal health information needed to American Medical AMA The AMA develps and maintains the http://www.ama- Association CPT codes assn.org/ama/pub/ category/3113.htm l American National ANSI The ANSI Federation’s primary goal is www.ansi.org Standards Institute to enhance the global competitiveness of U.S. business and the American quality of life by promoting and facilitating voluntary consensus standards and ensuring their integrity. American Nurses ANA Recognition of Nursing Terminologies: www.ana.org Association NIDSEC American Society for ASTM ASTM International is one of the largest www.astm.org Testing and Materials voluntary standards development organizations in the world-a trusted source for technical standards for materials, products, systems, and services. America's Health Insurance AHIP AHIP is the national association www.ahip.org Plans representing nearly 1.300 companies providing health insurance coverage to more than 200 million Americans. Centers for Medicare and CMS CMS is the Centers for Medicare & www.cms.hhs.gov/ Medicaid Services (CMS) Medicaid Services. CMS is the HHS medicare/hcpcs/ agency responsible for administering the Medicare, Medicaid, SCHIP (State Children's Health Insurance), and several other health-related programs. Clinicial Data Interchange CDISC CDISC develops and supports global, Standards Consortium platform-independent data standards that enable information system interoperability to improve medical College of American CAP research and related areas of of CAP is the original developer www.cap.org Pathologists SNOMED CT. SNOMED Terminology Solutions, part of CAP, provides education and consulting services to support the implementation of SNOMED- CT Digital Imaging & DICOM The DICOM Standards Committee Communications in exists to create and maintain Medicine® international standards for communication of biomedical diagnostic and therapeutic information in disciplines that use digital images and associated data. Health Information HITSP Healthcare Information Technology www.hitsp.org Technology Standards Standards Panel serves as a Panel cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States. Health Level Seven® HL7 Health Level Seven is an American National Standards Institute-accredited Standards Developing Organization operating in the healthcare arena. HL7's domain is clinical and administrative data, and its mission is: "To provide standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of healthcare services." www.hl7.org Institute of Electrical and IEEE A non-profit organization, IEEE is the www.ieee.org Electronics Engineers, Inc. world's leading professional association for the advancement of technology Integrating the Healthcare IHE IHE is an initiative by healthcare www.ihe.net Enterprise initiative professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinates use of established standards such as DICOM and HL7 to address specific clinical need in support of optimal patient care. Internation Council of ICN The Internation Council of Nurses is a www.icn.ch Nurses federation of national nurse's associations (NNA's) representing nurses in more than 128 countries. Founded in 1899, ICN is the world's first International Classification ICNP The ICNP is a unified nursing language www..icn.ch/icnp.h for Nursing Practice system. It is a compositional terminology tm for nursing practice that facilitates the development of and the cross-mapping among local terms and existing terminologies International Health IHTSDO The IHTSDO® (International Health www.ihtsdo.org Terminology Terminology Standards Development Standards Organisation) has been established as Development an association under Danish Law, and Organization its purpose is to: - Acquire, own and administer the rights to SNOMED CT® other health terminologies and/or related standards, and other relevant assets (collectively, the "Terminology Products") - Develop, maintain, promote and enable the uptake and correct use of its Terminology Products in health systems, services and products around the world - Undertake any or all activities incidental and conducive to achieving the purpose of the Association for the benefit of the Members. International Health IHTSDO The IHTSDO is a non-for-profit Terminology Standards association and has the responsibilty for Development Organization the ongoing development, quality assurance, and distribution of SNOMED- CT www.ihtsdo.org International Medical IMIA Internation not-for-profit organization www.imia.org Informatics Association promoting medical infomatics in healthcare and biomedical research. Medicomp Systems Medicomp Systems, Inc. is a Virginia corporation specializing in the development of point-of-care tools for Electronic Medical Records. Medicomp www.medicomp.com was founded in 1978 by Peter S. Goltra National Committee on NCVHS Standardization has been a priority for www.hhs.ncvhs.go Vital and Health Statistics NCVHS for most of its 58 years, v beginning with its historic (and ongoing) work on the International Classification of Diseases (ICD). Soon after HIPAA was enacted, the Committee created the Subcommittee on Standards and Security to manage its additional responsibilities for advising the Secretary on the adoption of health data standards, monitoring their implementation, and regularly reporting to Congress on their status National Council of NCPDP NCPDP creates and promotes www.ncpdp.org Prescription Drug standards for the transfer of data to and Programs® from the pharmacy services sector of the healthcare industry. The organization provides a forum and support wherein our diverse membership can efficiently and effectively develop and maintain these standards through a consensus building process. NCPDP also offers its members resources, including educational opportunities and database services, to better manage their businesses. National Uniform Billing NUBC The National Uniform Billing Committee www.nubc.org Committee (NUBC) was brought together by the American Hospital Association (AHA) in 1975 and it includes the participation of all the major national provider and payer organizations. The NUBC was formed to develop a single billing form and standard data set that could be used nationwide by institutional providers and payers for handling health care claims. National Uniform Claim NUCC The National Uniform Claim Committee www.nucc.org Committee (NUCC) is a voluntary organization that replaced the Uniform Claim Form Task Force in 1995. The committee was created to develop a standardized data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payers. It is chaired by the American Medical Association (AMA), with the Centers for Medicare and Medicaid Services (CMS) as a critical partner. The committee includes representation from key provider and payer organizations, as well as designated standards maintenance National Health Information NHIN As a key element of the national health Network information technology strategy, the advancement of the Nationwide Health Information Network initiative will provide the foundation for interoperable, secure and standards-based health information exchange nationally. Office of the National ONC The Office of the National Coordinator http://www.hhs.go Coordinator for Health Information Technology v/healthit/onc/miss provides leadership for the development ion/ and implementation of a nationwide health IT infrastructure allowing secure and seamless exchange of data and records. The ONC advises the Secretary of HHS on health IT policies and initiatives, and coordinates the Department’s efforts to meet the President’s goal of making an electronic medical record available for most Americans by 2014. Public Health Data PHDSC The Public Health Data Standards www.phdatastand Standards Consortium Consortium (PHDSC) committed to ards.info/ bring a common voice from the public health community to the national efforts of standardization of health and healthcare information. VA’s National Drug File NDF-RT The VHA National Drug File Reference Reference Terminology Terminology (NDF-RT) maintains terminology used to code these medication properties: Mechanism of Action Physiologic Effect Structural Class Workgroup on Electronic WEDI Provides a forum for facilitating www.wedi.org Data Interchange improvements in information exchange and management including the development of strategies and tactics, definition of standards, the resolution of implementation issues, identification of best practices and the development and delivery of education and training programs. ent Organizations Standard Type SME (Subject Standard(s) Contact Matter Experts) Other Resources Contact information is found on the web site Code Revision ADA Members, please E-mail: Committee (CRC) use the toll-free email@example.com number on the back of your membership card; Direct dial, 312-440- 2500 Physicians’ Current Procedural Terminology® (CPT) Healthcare Informatics Standards Board, recognizing standards for HIT and Medical Devices. Works closely with HITSP and HIMSS on their initiatives Recognition of Nursing Dr. Carol J. Bickford by NIDSEC site: Terminologies: NIDSEC telephone at 301-628- http://nursingworld.org/ 5060 or via e-mail MainMenuCategories/T (firstname.lastname@example.org hePracticeofProfession g) for more alNursing/DocInfo/NIDS information. EC.aspx Healthcare Informatics (E31); (Continuity of Care Record) Healthcare Common Procedure Coding System (HCPCS) Electronic billing & EDI Standards ICD code updates and maintenance DRG Grouper Systematized Nomenclature of Medicine Clinical Terms® (SNOMED CT®) (SEE IHTSDO) American National HITSP Secretariat: Standards Institute Michelle Maas Deane mmaasdeane@ansi. org ; John Halamka, MD, HITSP Chair, ;jhalamka@caregrou p.harvard.edu; Joyce Sensmeier, Technical Manager, HITSP, jsensmeier@himss. org HL7 Transactions Mark McDougall Linda Fischetti RN CCOW Executive Director MS, U.S. CDA Health Level Seven Department of Arden Syntax 3300 Washtenaw Veterans Affairs, Avenue, Suite 227 Phone: 301-734- Ann Arbor, MI 48104- 0417 Email: 4261 linda.fischetti@med. Phone: (734) 677- va.gov, Term 7777 Expires on: 31-Dec- Fax: (734) 677-6622 2009 Email: markmcd@HL7.ORG Wireless standards, etc. IHE profiles SNOMED-CT Contact Information: http://www.ihtsdo.org/c ontact/ Systematized Rued Langgaards Vej Nomenclature of 7, 5 ; 2300 Medicine Clinical Copenhagen S; Terms® (SNOMED Denmark CT®) (SEE CAP) E-mail: info(at)ihtsdo.org Tel: +45 36 44 87 36 Fax: +45 36 44 87 36 CVR No: 30363434 NATO Cage Code No: R5643 DUNS No: 311306794 CCR and ORKLA certified Contact persons: Jennifer Zelmer, CEO jze(at)ihtsdo.org Service Requests: support(at)ihtsdo.org Medcin Standards include the 9240 East Raintree http://www.ncpdp.org/P SCRIPT standard for Drive, Scottsdale, AZ DF/NCPDP_101.pdf: ePrescribing (Version 85260-7518 Phone: NCDPD 101 10.0) (480) 477-1000 presentation Fax: (480) 767-1042 Pharmacy Services Fax: (480) 767-1043 Contact Names and numbers: http://www.ncpdp.org/a bout_contact.asp UB-XX email@example.com 1500 billing form Condition codes Provider Characteristic codes Provider taxonomy codes POC: John Loonsk NLM/UMLS Document Standards Standard Ty Standard Category AAMR Adaptive Behavior Scale Psyche Abnormal Involuntary Movement Scale Neuro (AIMS) Assessment Alzehemier Assessment Scale Psyche AIS (Abbreviated Injury Scale) Anatomical scoring tool Aldrete Scale (admission and discharge Anesthesia numerical scoring scale used for ) Assessment Slade Anorexic Behaviour Scale Apgar Score Newborn Assessment AVPU Scale Neuro Assessment Barthel Index ADL Assessment Beck Depression Inventory II Determine presence and severity of symptoms of depression. BIERI Scale(faces scale revised) Pain Assessment Braden Scale Pressure sore risk Bristol Language Assessment Scale Neuro Assessment Chest Pain Scale – (0-10) Chest Pain Assessment ???? Children's Coma Scale (Modified Glascow Neuro Scale) Assessment CIWA- Clinical Institute Withdrawal Alcohol Assessment for Alcohol (CIWA-Ar) scale Assessment Denver Developmental Scale Disability Rating Scale (0-29) Disability Scale FLACC (face legs activity cry Pain consolability) Observational Tool Assessment Glasgow Coma Scale Neuro Assessment Glasgow Outcome Scale Neuro Assessment Geriatric Depression Scale (GDS) Hendrich II Fall Risk Scale Falls Assessment Continuity of Care Record (CCR) Document Architecture Standard Care Record Summary (CRS) Document Architecture Standard HL7 Version 3.0 Clinical Document Document Architecture (CDA/CDA R2) Architecture Standard HL7 Version 3.0 Continuity of Care Document Document (CCD) Architecture Standard Likert Scale Rating/Respon se Scale Lund and Browder Chart - Rule of Nines Burn Assessment Mini Mental State Exam (MMSE) Mental Assessment Modified Wong-Baker Faces Scale (0-10) Pain Assessment Morse Falls Scale Falls Assessment NIH Stroke Scale (NIHSS) Stroke Scale Assessment Neonatal Infant pain Scale (NIPS) Pain Assessment Numerical Rating Scale (0-10) (NRS) Pain Assessment PABS (Pain assessment behavioral scale) Pain Assessment PIPP (Premature Infant Pain profile) – Pain neonates Assessment Poker Chip Scale (faces scale)? Pain Assessment Ramsay Scale Sedation Assessment Rancho Los Amigos – original and Cognitive revised Function Assessment Respiratory Index Riker Sedation Agitation Scale Sedation Assessment Social Adjustment Scale Neuro Assessment Stroke Risk Assessment Neuro Assessment Suicide Intent Scale Psyche Beck Scale for Suicide Ideation Psyche Trauma and Injury Severity Scale Trauma Assessment Scale VDS (Verbal Descriptor Scale) Pain Assessment VRS (Verbal Rating Scale) Pain Assessment Visual Analog Scale (Faces Scale) Pain *research with other faces scales Assessment Waterloo Pressure Sore Risk Score Pressure sore risk Document Standards Standard Type Contact Description Developer Assesses the ability of individuals who are mentally American Association Lambert, Nadine, retarded, emotionally maladjusted, or developmentally on Mental Retardation Nihira, Kazuo, disabled to cope with the natural and social demands Leland, Henry, of their environment. It is available in two versions, http://www3.parinc.c one for residential and community settings, the other om/products/product for schools. .aspx?Productid=AB S-S:2 This tool helps to detect and assess the level of National Mental Health http://www.dr- possible dyskinesias in patients taking antipsychotic Association bob.org/ medications. Comes complete with an instructional video showing what the symptoms look like and how to score them. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance. The Alzheimer's Disease Assessment Scale (ADAS) Paul R. Solomon, PhD; takes 45 minutes administered by a trained observer Aliina Hirschoff; Bridget and is a standardised assessment of cognitive Kelly; Mahri Relin; function and non-cognitive features. The cognitive Michael Brush; Richard section of the scale (ADAS-Cog) is the gold standard D. DeVeaux, PhD; for measuring change in cognitive function in drug William W. Pendlebury, trials. Deterioration of about 10% per year in cognitive MD tests in patients with Alzheimer's disease is regarded as average. The cognitive domains include components of memory, language and praxis, while the non-cognitive features include mood state and behavioural changes. There are 11 main sections testing cognitive function and 10 assessing non- cognitive features. The Abbreviated Injury Scale (AIS) is an anatomical Association for the http://www.fernoedu scoring system first introduced in 1969. Since this Advancement of cation.it/en/Abbrevia time it has been revised and updated against survival Automotive Medicine, ted%20Injury%20Sc so that it now provides a reasonably accurrate was of Baltimore, MA, USA ale.pdf. ranking the severity of injury. The latest incarnation of 205-218 the AIS score is the 1990 revision. The AIS is Association for the monitored by a scaling committee of the Association Advancement of for the Advancement of Automotive Medicine. Automotive Medicine2340 Des Injuries are ranked on a scale of 1 to 6, with 1 being Plaines Avenue, Suite minor, 5 severe and 6 an unsurvivable injury. This 106Des PlainesIllinois represents the 'threat to life' associated with an injury 60018USA and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale, in that the difference between AIS1 and AIS2 is not the same as that between AIS4 and AIS5. Organ Injury Scales of the American Association for the Surgery of Trauma are mapped to the AIS score for calculation of the Injury Severity Score. The patient is discharged from the PACU when he or http://www.virginia.e she meets established criteria for discharge, as du/uvaprint/HSC/pdf determined by a scale. One example is the Aldrete /33467.pdf scale, which scores the patient's mobility, respiratory status, circulation, consciousness, and pulse oximetry. Depending on the type of surgery and the patient's condition, the patient may be admitted to either a general surgical floor or the intensive care unit. Since the patient may still be sedated from anesthesia, safety is a primary goal. The patient's call light should be in the hand and side rails up. Patients in a day surgery setting are either discharged from the PACU to the unit, or are directly discharged home after they have urinated, gotten out of bed, and tolerated a small amount of oral intake. A 22 item scale for assessing anorexic behaviour. P.D. Slade Measures 3 dimensions of behaviour: 1)Resistance to eating; (2)methods of disposing of food; and (3) 'overactivity'. It was designed to be administered by observers who would evaluate patients on a hospital ward. The very first test given to your newborn, the Apgar Virginia Apgar http://www.childbirth. score occurs right after your baby's birth in the org/articles/apgar.ht delivery or birthing room. The test was designed to ml quickly evaluate a newborn's physical condition after delivery and to determine any immediate need for extra medical or emergency care. Although the Apgar score was developed in 1952 by an anesthesiologist named Virginia Apgar, you may have also heard it referred to as an acronym for: Activity, Pulse, Grimace, Appearance, and Respiration. The Apgar test is usually given to your baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Rarely, if there are concerns about the baby's condition and the first two scores are low, the test may be scored for a third time at 10 minutes after birth. The AVPU scale is a system by which a First aider, http://www.mindef.g Ambulance crew or other suitably trained person, can ov.sg/joint/smti/wap/ measure and record the consciousness level of a avpu.htm patient The Barthel Index consists of 10 items that measure Barthel DW: http://www.dundee.a a person's daily functioning specifically the activities c.uk/medther/Stroke of daily living and mobility. The items include feeding, /Scales/barthel.htm moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing, continence of bowels and bladder. How is the Barthel Index used? The assessment can be used to determine a baseline level of functioning and can be used to monitor improvement in activities of daily living over time. The items are weighted according to a scheme developed by the authors. The person receives a score based on whether they have received help while doing the task. The scores for each of the items are summed to create a total score. The higher the score the more "independent" the person. Independence means that the person needs no assistance at any part of the task. If a persons does about 50% independently then the "middle" score would apply. In the United Kingdom quite frequently the 5, 10 and 15 scores are substituted by 1, 2, and 3. This gives a potential maximum of 20 rather than 100. The Beck Depression Inventory Second Edition (BDI- http://www.cps.nova. II) is a 21-item self-report instrument intended to edu/~cpphelp/BDI2. assess the existence and severity of symptoms of html depression as listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV; 1994). This new revised edition replaces the BDI and the BDI- 1A, and includes items intending to index symptoms of severe depression, which would require hospitalization. Items have been changed to indicate increases or decreases in sleep and appetite, items labeled body image, work difficulty, weight loss, and somatic preoccupation were replaced with items labeled agitation, concentration difficulty and loss of energy, and many statements were reworded resulting in a substantial revision of the original BDI and BDI-1A. When presented with the BDI-II, a patient is asked to consider each statement as it relates to the way they have felt for the past two weeks, to more accurately correspond to the DSM-IV criteria. Faces scale- a scale for measurement of pain Bieri D http://painsourceboo intensity in children by self-report, in English, French k.ca/pdfs/pps92.pdf and other languages. The Faces Pain Scale - Revised (FPS-R) was adapted from the Faces Pain Scale (Bieri et al, 1990) in order to make it possible to score on the widely accepted 0-to-10 metric. It shows a close linear relationship with visual analog pain scales across the age range 4 through 16 years. It is easy to administer and requires no equipment except for the photocopied faces. The absence of smiles and tears in this faces scale may be advantageous. The FPS-R is recommended for use with younger children in parallel with numerical self-rating scales (0-to-10) for older children and behavioural observation scales for those unable to provide self-report. Braden scale is the assessment of presure sore ulcer Barfbara Braden http://www.bradensc risk of measured of the total score of the Braden ale.com/braden.PDF score as defined by the Braden scale. Bristol laanguage development scale (And UK used scale) is a scale of a 30 minute audiotaped sample of the child's spontaneous verbal output scored from 0 to 10 on the Bristol language development scales One of the components of the Glasgow coma scale is Institute for the best verbal response, which cannot be assessed Algorithmic in nonverbal small children. A modification of the Medicine, Houston, original Glasgow coma scale was created for children TX, USA too young to talk. Parameters: http://trauma.ucsd.e du/Portals/0/47%20 (1) eyes opening GCS.pdf (2) best verbal or nonverbal response (depending on development status) (3) best motor response Older adults do not always show withdrawal signs in the same way that that younger adults do. For example, older adults may not demonstrate signs of anxiety, shakes, or sweating. Alternatively, the signs may be confused with other medical conditions that the older adult has, such as Parkinson's disease. In other cases, the person may have some degree of cognitive impairment and may not be able to accurately tell you how she or he is feeling. For that reason, monitoring vital signs before withdrawal (and having a baseline of what is normal for this person) and during withdrawal can provide very important information. This clinical tool assesses 10 common withdrawal signs. A score of 15 + points means the patient may be at increased risk of alcohol withdrawal effects such as confusion or seizures. Clinicians working with older adults note that a lower cutoff is advisable for older adults, as a score of more than 15 may mean a potential health crisis. The Denver Developmental Screening Test (DDST), William K. Frankenburg http://www.patient.c commonly known as the Denver Scale, is a test for o.uk/showdoc/40000 screening cognitive and behavioural problems in 554/ preschool children. It was developed by William K. Frankenburg and first introduced by him and J.B. Dobbs in 1967. The test is currently marketed by Denver Developmental Materials, Inc., in Denver, Colorado, hence the name.The scale reflects what percentage of a certain age group is able to perform a certain task. In a test to be administered by a pediatrician or other health or social service professional, a subject's performance against the regular age distribution is noted. Tasks are grouped into four categories (social contact, fine motor skill, language, and gross motor skill) and include items such as smiles spontaneously (performed by 90% of three-month-olds), knocks two building blocks against each other (90% of 13-month-olds), speaks three words other than "mom" and "dad" (90% of 21-month- olds), or hops on one leg (90% of 5-year-olds). Rappport et al developed a disability rating scale for patients who have had severe head injury with coma. This can help evaluate a patient's level of disability and monitor rehabilitation into the community. The authors are from the University of California in San Francisco and the Santa Clara Valley Medical Center in San Jose. Parameters: (1) arousability awareness and responsivity (based on a modified Glasgow Coma Score using eye opening verbalization and motor response) (2) cognitive ability for self-care activities in: feeding toileting grooming (3) dependence on others and level of functioning (4) psychosocial adaptability and employability The FLACC scale was developed to reduce these potential barriers by providing a simple framework for assessment, while facilitating a reliable and objective means of quantifying pain behaviors in children. This tool includes five categories of pain behaviors, including facial expression, leg movement, activity, cry, and consolability. These behaviors are consistent with those described by Büttner and Finke (2000) to be reliably associated with pain in young children. The acronym FLACC facilitates recall of these categories, each of which is scored from 0-2 to provide a total pain score ranging from 0-10. The FLACC tool was shown to have good interrater reliability and excellent validity as demonstrated by changes in pain scores from before to after analgesic administration and excellent correlation with the Objective Pain Scale (OPS) in a study of children aged 2-7 years (Merkel et al., 1997). The Glasgow Coma Scale or GCS, sometimes also The scale was known as the Glasgow Coma Score is a neurological published in 1974 by scale which aims to give a reliable, objective way of Graham Teasdale and recording the conscious state of a person, for initial as Bryan J. Jennett, well as continuing assessment. A patient is assessed professors of against the criteria of the scale, and the resulting neurosurgery at the points give a patient score between 3 (indicating deep University of Glasgow. unconsciousness) and either 14 (original scale) or 15 The pair went on to (the more widely used modified or revised scale). author the textbook GCS was initially used to assess level of Management of Head consciousness after head injury, and the scale is now Injuries (FA Davis used by first aid, EMS and doctors as being 1981, ISBN 0-8036- applicable to all acute medical and trauma patients. In 5019-1), a celebrated hospital it is also used in chronic patient monitoring, in work in the field. for instance, intensive care. The Glasgow Outcome Scale (GOS) was commonly used before other scales were developed. As a brief descriptive outcome scale it has been replaced by the DRS, although it is still seen occasionally in the literature, especially in studies investigating early acute medical predictors of gross outcome. The five categories of the original scale are: dead, vegetative, severely disabled, moderately disabled, and good recovery. An extended version of the scale divides each of the latter three categories in two, making The GDS questions are answered "yes" or "no", The GDS was first instead of a five-category response set. This simplicity developed in 1982 by enables the scale to be used with ill or moderately J.A. Yesavage and cognitively impaired individuals. The scale is others commonly used as a routine part of a comprehensive geriatric assessment. One point is assigned to each answer and the cumulative score is rated on a scoring grid. The grid sets a range of 0-9 as "normal", 10-19 as "mildly depressed", and 20-30 as "severely depressed". A diagnosis of clinical depression should not be based on GDS results alone. Although the test has well-established reliability and validity evaluated against other diagnostic criteria, responses should be considered along with results from a comprehensive diagnostic work-up. A short version of the GDS containing 15 questions has been developed, and the scale is available in languages other than English. Derived from 20 years of research, the Hendrich II Fall Risk Model®, is an evidenced based tool for identification of patients at risk for falls. The AHI Fall Prevention Program will help your organization meet JACHO goals and Magnet standards. The Centers for Medicare and Medicaid ( CMS) may soon add falls to the list of events that should not occur in hospitals –“Never Events” Designed and implemented as a standard for a Specification developed comprehensive data summary that aggregated data jointly by ASTM from multiple sources, health care records, medical International, the legal documents, and health encounters to form a Massachusetts Medical comprehensive overall clinical picture of a patient's Society (MMS), current and relevant historical health care status. It is HIMSS (HIMSS), the officially balloted and approved as ASTM Standard American Academy of E2369-05 Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors. Original HL7 attempt at patient care integration standard, later incorporated into HL7 CDA Designed to represent medical legal health care encounter documents in a statndardized format. Uses XML, The HL7 Reference Information Model (RIM) and vocabulary. Developed to resolve the CCR vs CDA. The CCD was The CCD is a developed as a harmonization between the CCR and compromise, joint effort the CDA, using the semantic model from CCR, of two rival standards- expressed in the CDA XML schema. Though this development compromise was reached in the industry and ratified organizations, ASTM by HITSP, the debate over CCR vs. CDA remains. International and Health Level 7 but the CCD will be a component of HL7's overarching Clinical Document Architecture and thus will be balloted by HL7 members only. A psychometric response scale often used in Rensis Likert N/A questionnaires, and is the most widely used scale in survey research. When responding to a Likert questionnaire item, respondents specify their level of agreement to a statement. The scale is named after Rensis Likert, who published a report describing its use Introduced in the 1940s by Pulaski and Tennison as a quick assessment took for determining the size of a burn injury. Often used in pre-hospital settings or in the ED to obtain a general estimate of the extent of the burn. Based on the presumption that the body can be divided into nine anatomic regions that represent 9% of the entire body surface. It is reasonably accurate in individuals 9 years of age and older. However, in infants and children, the rule of nines calculation is different because of the relatively larger surface area of the head and the smaller area of the lower extemities. The mini-mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to assess cognition. It is commonly used in medicine to screen for dementia. In the time span of about 10 minutes it samples various functions including arithmetic, memory and orientation. It was introduced by Folstein et al in 1975, and is widely used with small modifications. This test is not the same thing as a mental status examination A visual analog scale to assess pain in pediatric Donna Wong, a nurse Donna Wong, PhD, patients consultant, and Connie RN Morain Baker, a child Nursing Consultant life specialist, were & Assoc Professor working in the burn Univ of Oklahoma & center at Hillcrest Oral Roberts Univ Medical Center, Tulsa, 7535 S Urbana OK. Avenue Tulsa, OK 74136- 6113 918-496-0544 Morse (1997) developed the Morse Falls Scale Janice M. Morse (MFS), which consists of six items: history of falling; presence of a secondary diagnosis; use of an ambulation aid; intravenous therapy; type of gait; and mental status. It has the advantage of ease of scoring through a chart audit or direct observation. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome The Neonatal Infant Pain Scale (NIPS) is a behavioral developed at the assessment tool for measurement of pain in preterm Children's Hospital of and full-term neonates. This can be used to monitor a Eastern Ontario. neonate before during and after a painful procedure such as venipuncture. On the numerical rating scale, the person is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable). The Rancho Levels of Cognitive Functioning is an Rancho Los Amigos evaluation tool used by the rehabilitation team. The National Rehabilitation eight levels describe the patterns or stages of Center. recovery typically seen after a brain injury. This helps the team understand and focus on the person's abilities and design an appropriate treatment program. Riker and colleagues performed a study to test the Riker Sedation-Agitation Scale (SAS) for reliability and validity in adult ICU patients (2). The SAS includes seven levels of agitation, ranging from dangerous agitation to unarousable. Paired evaluators (experienced ICU nurses) simultaneously and independently scored patients using the SAS, Ramsey, and Harris scales. Reliability was confirmed for all scales by the high interrater proportion of agreement (0.95). Validity was established based on a high correlation with the Ramsey and Harris scales. The SAS of Weissman and colleagues (1974, 1976, 1978) was derived from The Structured and Scaled Interview to Assess Maladjustment (SSIAM; Gurland, Yorkston, Stone, Frank, and Fleiss, 1972) and has been widely used in psychiatric and non-psychiatric groups. The suicide intent scale was developed by Aaron T. Aaron T. Beck et al. Beck and his colleagues at the University of Pennsylvania for use with patients who attempt suicide but survive. It is important to understand a patient's will to die in order to assess the severity of the suicide attempt. Some attempted suicides are carried out with little to no intention of cessation of life, while others clearly have no other goal. The suicide intent scale is an attempt to redefine the meaning of attempted suicide, placing them on a scale based on intent. The Beck Scale for Suicide Ideation (BSI; Beck & Steer, 1991) is a 21-item self-report instrument for detecting and measuring the current intensity of the patients' specific attitudes, behaviors, and plans to commit suicide during the past week. The BSI was developed as a self-report version of the interviewer- administered Scale for Suicide Ideation. The first 19 items consist of three options graded according to the intensity of the suicidality and rated on a 3-point scale ranging from 0 to 2. These ratings are then summed to yield a total score, which ranges from 0 to 38. Individual items assess characteristics such as wish to die, desire to make an active or passive suicide attempt, duration and frequency of ideation, sense of control over making an attempt, number of deterrents, and amount of actual preparation for a contemplated attempt. The last two items assess the number of previous suicide attempts and the seriousness of the intent to die associated with the last attempt. As with the SSI, the BSI consists of five screening items. If the respondent reports any active or passive desire to commit suicide, then an additional 14 items are administered. The BSI takes approximately 10 minutes to administer. The verbal rating scale (VRS) originated by Melzack is a simple, commonly used pain rating scale. To complete it, subjects select one of six descriptors that represent pain of progressive intensity: none, mild, discomforting, distressing, horrible, or excruciating. Another scale is a modified 21-point Box Scale. The scale has a row of 21 boxes labeled from 0 to 100 in increments of five. The 0 anchor is labeled "no pain," while the 100 anchor is labeled "pain as bad as it could be." To complete the scale, respondents indicate the box that best represents their pain. The horizontal visual analog scale (HVAS) consists of a 10 cm line anchored by two extremes of pain: no pain and extreme pain (Figure 1). Patients are asked to position a sliding vertical marker to indicate the level of pain they are currently experiencing; pain severity is measured as the distance in centimetres between the zero position and the marked spot.[11- 13] The vertical visual analog scale (VVAS) is similar to the prior scale but is presented vertically, and the line is replaced by a red triangle with its summit facing downwards (no pain=0) and its base at the top (maximum pain=10); the use of this scale has been validated in children SME (Subject Recogntion Matter Experts) Other Resources <http://www.enotes.com/me ntal-disorders-encyclopedia/ abnormal-involuntary- movement-scale> Hahn YS, Chyung C, et al. Head injuries in children under 36 months of age. Child's Nerv Syst. 1988; 4: 34-40. Jaffe D, Wesson D. Emergency management of blunt trauma in children. N Engl J Med. 1991; 324:1477- 1482. Simpson D, Reilly P. Pediatric Coma Scale (Letter to the Editor). Lancet. 1982; 2: 450 Ann Hendrich http://www.ahincorp.com/ HITSP Named Standard HITSP Named Standard N/A N/A N/A http://www.minimental.com/ The Clinical Guide by Marshal F. Folstein, MD, Susan E. Folstein, MD, and Gary Fanjiang, MD, describes the development, validation, administration, and interpretation of the MMSE Donna Wong, PhD, http://www.mosbysdrugcons RN and Carol Baker, ult.com/WOW/facesReprod PhD, RN uctions.html Family Education Resource: http://www.rancho.org/patien t_education/bi_cognition.pdf Infrastructure Standards Standard Type Standard Acronym Description cancer Common Ontology caCORE caCORE is open source software and Reference Envi-ronment services developed by the National Cancer Institute Center for Bioinformatics (NCICB) Core Infrastructure Group. Providing a data management and application development framework caCORE- based systems include the semantic underpinning for interoperable data and analytical services Federal Health Architecture FHA The Federal Health Architecture (FHA) was established as an eGov Line of Business in response to The President's Management Agenda calling for increased efficiency and effectiveness in government operations. The FHA is responsible for leveraging federal expertise in creating a federal framework that would be derived from a national health IT infrastructure, supporting federal activities in the development and adoption of health IT standards, and ensuring that federal agencies can seamlessly exchange health data between and among themselves, with state, local and tribal governments, and with private sector healthcare organizations. Information Technology (IT) IT Infrastructure Integrating the Healthcare Enterprise Infrastructure Technical Technical (IHE) Technical Frameworks, are a Framework Framework resources for users, developers and implementers of healthcare imaging and information systems. They define specific implementations of established standards to achieve effective systems integration, facilitate appropriate sharing of medical information and support optimal patient care. They are expanded annually, after a period of public review, and maintained regularly by the IHE Technical Committees through the identification and correction of errata.Ten IHE IT Infrastructure Integration Profiles are specified as Final Text in Version 4.0 of the ITI Technical Framework (ITI-TF v. 4.0): Cross-Enterprise Document Sharing (XDS), Patient Identifier Cross- Referencing (PIX), Patient Demographics Query (PDQ), Audit trail and Node Authentication (ATNA), Consistent Time (CT), Enterprise User Authentication (EUA), Retrieve National Health Information NHIN (formerly The Nationwide Health Information Network (formerly National NHII) Network (NHIN) network of networks, is Health Information the critical portion of the health IT Infrastructure) agenda intended to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. The NHIN will enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health. Pulic Health Information PHIN PHIN is a national initiative to improve Network the capacity of public health to use and exchange information electronically by promoting the use of standards, defining functional and technical requirements. PHIN strives to improve public health by enhancing research and practice through best practices related to efficient, effective, and interoperable public health information systems MedBiquitous is a non-profit, MedBiquitous Based on XML and Web services dedicated to advancing standards, this blueprint will weave healthcare education through together the many activities, technology standards to organizations, and resources that create a technology blueprint support the ongoing education and for professional healthcare performance of healthcare education. professionals, creating more integrated access to educational resources, scientific journals, pharmaceutical and device product information, and clinical trials and registries. Ultimately, this blueprint will seamlessly support the learner in ways that will improve patient care and simplify the administrative work associated with education and competence assessment. Consolidated Health CHI Adopts a portfolio of existing health Informatics information interoperability standards (health vocabulary and messaging) enabling all agencies in the federal health enterprise to “speak the same language” based on common enterprise- wide business and information technology architectures structure Standards Standard Type Contact SME (Subject Developer Matter Experts) Other Resources National Cancer Intitute Deering Mary Jo Deering Mary Jo 1.Enterprise Vocabulary Services (NCI) firstname.lastname@example.org. email@example.com. (EVS); 2.Cancer Data Standards gov gov Repository (caDSR); 3. cancer Bioinformatics Infrastructure Objects (caBIO) model. HHS-Office of National firstname.lastname@example.org Health Information Technology Coordinator (ONC) Policy Council (HITPC); Healthcare Information Technology Standards Panel (HITSP); Consolidated Health Informatics (CHI) is an integral element of the Federal Health Architecture (FHA). Integrating the http://www.ihe.net/T Didi Davis IT Infrastructure White Papers Healthcare Enterprise echnical_Framewor email@example.com The IHE IT Infrastructure Technical (IHE) k/index.cfm Committee has published the following white papers for public comment. These white papers facilitate the use of existing IHE ITI profiles or scope the need for future profiles.Comments can be submitted to the online discussion forums at http://forums.rsna.org HHS-Office of National http://www.hhs.gov/ Summary Report on the Prototype Coordinator (ONC) healthit/healthnetwor Architectures (PDF - 1.73MB) k/forums/ 1st Executive Order National Committee on Vital and Health Statistics Recommendations on the initial functional requirements for a Nationwide Health Information Network (NHIN) Centers for Disease http://www.cdc.gov/p The National Electronic Disease Control and Prevention hin/about.html Surveillance System (NEDSS); (CDC) PHIN Vocabulary Services, PHIN XForms Question Framework PHIN Messaging Services PHIN Messaging System Office of Management Vish Sankaran, FHA and Budget's (OMB) Acting Program eGov initiatives. Manager Standards Workgroup 1 Review and Comments Due: EOD Wednesday, May 28th. Conference call to discuss results Thursday, May 29, 11amEDT Please register at https://www1.gotomeeting.com/register.970297086 Instructions: Enter your comments, additions, revisions, etc on this tab. In the column for Tab name, use the dropdown list to select the spreadsheet tab you are referring to. In the column "Line#/Standard" if you are referring to an existing entry, enter the spreadsheet line # and standard name. In the column "comment by" enter your name. Tab Name Line Comment by: #/Standard Jsensmeier Terminology Classification Cyndie Lundberg terminologies standard description Standards CMS- row # 8 Cyndie Lundberg Initiatives Standards Orgs SNOMED Cyndie Lundberg Row # 10 Document Row #38 Cyndie Lundberg Standards Document Virginia Saba Standards Standards Row 19 Ginny Meadows Initiatives Terminology Ginny Meadows Terminology Ginny Meadows Standards Ginny Meadows Initiatives Standards Ginny Meadows Initiatives Data Rita Zielsdorg Exchange_Mes saging Document Standards Standards Workgroup 1 Review and Comments h. Conference call to discuss results Thursday, May 29, 11amEDT gotomeeting.com/register.970297086 ons, revisions, etc on this tab. down list to select the spreadsheet tab you are referring to. referring to an existing entry, enter the spreadsheet line # and standard name. ame. Comment I made changes in red throughout the document. In some cases I suggested deletions. I also suggested phone numbers be removed. For all of the classification systems, we need to rewrite the description of the classification in easier natural language so all can be understood. CMS is currently working with the Health and Human Services (HHS) to map the Minimum Data Set (CMS) Version # 3.0 to SNOMED CT and LOINC College of American Pathologist (CAP) is the original developer of SNOMED Reference Terminology that became SNOMED CT in 2002. In May, 2007 SNOMED CT transitioned to the International Health Terminology Standards Development Organization (IHTSDO) to encourage global adoption. SNOMED Terminology Solutions, part of CAP, provides education and consulting services to support the implementation of SNOMED-CT globally. Geriatric Depression Scale Rosemary Kennedy can send a list of all these tools with descriptions. I added the USHIK to the list Changed the description of LOINC to incorporate the clinical observations Replaced Terminology Tab with new tab sent by Cindie Lundberg Should we delete the "Developer" column in this tab - as N/A? Need to complete the contact and SME columns, if applicable Add the National Council for Prescription Drug Programs (NCPDP) Need to complete this tab - see #10 above s DT Resolution GM- I incorporated all of Joyces changes in the new document. We will keep the phone numbers as long as they are publicly available on the website This will be done during the editing process Ginny will incorporate Data Exchange_Messaging Ginny will incorporate Terminology Standards Initiatives Virginia will contact Rosemary. Standards Orgs Done, everyone OK with it. Document Standards Done, Cindy OK with it. Infrastructure Done, Cindy OK with it. Yes, deleted Ginny will incorporate Ginny will incorporate Cyndie and Ginny will work on it.
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