As a Health Information Management (HIM) / Medical Records (MR) practitioner, you will be very familiar with data collected in manual forms and in electronic systems along with the clinical and medical terms the care providers use in your hospital to document the patient care.
To go on with the Joint Commission International (JCI) Standard MCI.13 from my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window), I think you need to know a little introduction about data since you will be part of the Management of Communications and Information Committee discussing along side with a representative from the hospital Information Technology (IT) department. The Joint Commission International (JCI) Standard MCI.13 does not specify a need to know about data elements and the workings of a Hospital Information System (HIS).
A piece of data that you encounter each day is the data element, which is a basic unit of information collected about anything of interest – for example, a pharmaceutical name or the city in which a patient lives. All the data elements reside in a data dictionary which is a collection of data element and their definitions. The data set refers to a commonly agreed upon collection of data elements found in your HIS and is a standard method for collecting and reporting these individual data elements. The data set used for collection and reporting purposes depends on patient type, for example a data set for oncology (study of cancer) when data is collected on cancers in acute care hospitals and reported to a national cancer registry nationwide.
What a HIM/MR practitioner does need to know that concerns this standard is about what is a medical vocabulary, medical nomenclatures, and classification systems.
A nomenclature is a systematic listing of the proper names. When health care providers document patient care they use a medical nomenclature, for example the Systematized Nomenclature of Medicine (SNOMED) which is a vocabulary of clinical and medical terms (e.g., myocardial infarction, diabetes mellitus, appendectomy, and so on), is used in more than 40 countries (Prathibha 2010).
Medical vocabulary is a system of disease names with explanations of their meanings. A medical coding system (or medical classification system) then organises the clinical and medical terms in a medical vocabulary (the medical nomenclature) into categories according to similar conditions, diseases, procedures, and services and establishes codes (numeric and alphanumeric characters) for each.
Several medical classification systems exist, of which any HIM/MR practitioner would be most familiar with is ICD-10, which is entitled the International Statistical Classification of Diseases and Related Health Problems (ICD-10). While most WHO member states had started to adopt ICD-10 by 1994, the health care system in the United States continues to use the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) as its official system of assigning codes to diagnoses and procedures related to hospital use. Also in the U.S., ICD-10-PCS, a procedural classification system is intended to replace ICD-9 volume 3 for reporting of inpatient procedures while Current Procedural Terminology (CPT) is still used for all outpatient procedures.
Diagnoses and procedures codes are reported to third-party payers for reimbursement as in the U.S., to external agencies for data collection, and internally for education and research in most countries. Standard terminology enables data capture to proceed in a structured manner, facilitating the collection of information and enhancing the ability to perform data analyses.
Your hospital will be checked for compliance to this standard and hopefully your hospital is prepared to fully meet the four (4) measurable elements of JCI Standard MCI.13 which measure if (i) only standardised diagnosis codes and procedure codes for example ICD-10 or ICD-10 PCS are used and monitored, and (ii) standardised definitions, symbols, and abbreviations are used and their usage monitored but (iii) ensuring that those symbols and abbreviations not to be used are identified and monitored as well.
Potential sources of errors at each step of the disease coding process using standardised diagnosis codes and procedure codes must be monitored by the HIM/MR department during routine and/or random checks of medical records to ensure code accuracy. Increased attention to monitoring code accuracy is important as it directly impacts the quality of decisions that are based on codes as a result of the application of ICD codes for purposes other than those for which the classifications were originally designed as well as because of the widespread use for making important funding for example casemix, clinical, and research decisions.
Standardised definitions, symbols, and abbreviations use – taking into account those symbols and abbreviations that are not to be used (that is the Do Not Use List) must be monitored as I posted in my previous post JCI Standard MCI.13 – Use of standardised symbols and abbreviations (this link will open in a new tab of your current browser window).
A hospital must also ensure that standardisation of diagnosis codes and procedure codes, definitions, symbols, and abbreviations usage is consistent with recognised local and national standards and even international standards and best practices.
With this post, I think I briefly blogged about the implications of JCI Standard MCI.13 and your role as a HIM/MR practitioner in ensuring compliance to this standard.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA
