Standards: Required for Health Information Management

The term “standard” has a number of definitions in health information management. The healthcare media groups frequently include this word in tandem with other familiar buzz words, including interoperability, standardization, standards development organizations, harmonization, “meaningful use” of electronic health records, Health Level Seven (HL7), ICD-10-CM/PCS, SNOMED CT, LOINC, Rx Norm, and health information exchange projects.

If one were to ask a health information management (HIM) professional about standards used in their daily work, the results would be variable since standards for healthcare mean different things to different people and organizations. The Oxford dictionary has eight definitions as a noun and another four as an adjective. The first Oxford dictionary defines a standard as “an object or quality or measure serving as a basis or example or principle to which others conform or should conform or by which others are judged (by present day standards).” This definition uses many “or’s” and a “should’’ to demonstrate attributes of standards, and to emphasize importance in advancing specified goals. It is no secret that the HIM profession is keen to have the healthcare industry conform to recognized standards authorities and achieve compliance with HIM practice standards, published guidance, and principles.

  • AHIMA’s Pocket Glossary of Health Information Management and Technology offers this definition: “A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured”. The second definition of standard is stated as “a model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, value, or quality.”
  • The ISO/IEC Guide 2 published in 2004 defines a standard as a “document, established by consensus and approved by a recognized that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context.” A separate note is included that states, “Standards should be based on the consolidated results of science, technology and experience, and aimed at the promotion of optimum community benefits.”

 

The answer provided by HIM professionals to the question posed previously may include many different views of “standards” affecting their work, including those listed in the table below. The term “global” when linked to standards is used to describe standards used in more than one country. ISO standards are described as international standards developed by the International Organization for Standardization.

 

Selected Standards Used in HIM

Example

Local – National- International Global

 

Classification standards The World Health Organization (WHO) provides the International Classification of Diseases which is a standard for classifications used in many countries, including the United States Global
Terminology standards Problem lists encoded using SNOMED CT which is a standardized nomenclature of medicine providing clinical terms and documentation support Global
Messaging and transport standards HL7 Decision Support Service (DSS), Release 1 International
Informatics standards Electronic Health Record Functional Model Release 1 International
Records management standards (for the management of business records) ISO 15489-1:2001 Information and documentation—Records management—Part 1: General

 

International
HIM Practice Standards Written policies and procedures guide the processing and reporting of healthcare information and are consistent with classification principles and data element definitions Generally Local or National—may be global/international

 

Accreditation Standards Joint Commission Interim Requirements for Physical Exam in Residential Setting Aopplicable to Behavior Health Care Effective January 11, 2011

Standard CTS.02.01.07: For 24-hour setting: The organization completes a physical health assessment, including a history and physican examination.

National/International

 

(if the organization is operated by the US government, under a charter of the US Congress)

 

Mandated Standards Health Insurance Portability and Accountability Act (HIPAA) of 1996 National
Data Standards The agreed upon specifications for the values acceptable for specific data fields

(i.e., Date = mm/dd/yy)

Local/National/International

 

The term “data standards” can be confusing because there are many types and these standards are very important in healthcare efficiency and maturity of electronic health records and information interchange. An alternate term frequently used is “data content standards” which is frequently used in the context of health information exchange using electronic networks. Data standards are basically an agreed set of rules that enable information to be shared and processed in a consistent manner. In fact data standards are found in this article—such as the grammar requirement to end sentences with a period.

Clinical data standards include terminology standards, conceptual standards such as the Unified Medical Language System from the National Library of Medicine, and document standards such as the Continuity of Care Document. Messaging standards include medical device messaging and application standards. Progress is slow for the establishment of a set of health information data standards due to the complexity of medicine.

Without incentives, adopting data standards can be difficult. Government mandates and national initiatives including the Standards & Interoperability framework supported by the Office of the National Coordinator are making good progress towards the goal of transforming efficient and useful data standards to support health information exchanges. One resource for exploring existing data standards and data sets for healthcare is the United States Health Information Knowledgebase.

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