Since the implementation of the Health Information Technology for Economic and Clinical Health Act, many eligible professionals and hospitals have taken advantage of the incentives provided through the Meaningful Use Stage 1 program. ICD and non-ICD terminologies are referenced in the final rules issued by the Office of the National Coordinator for Health Information Technology (ONC), which outlines the set of standards, implementation specifications, and certification criteria for electronic health record (EHR) technology and the final rule issued by the Centers for Medicare and Medicaid Services on the meaningful use EHR Incentive Program. With this expanded need to capture and encode health data, HIM professionals are being called upon to view the world of code sets in a new light.

AHIMA’s revised “Meaningful Use Vocabulary Toolkit” describes the vocabulary standards adopted in the ONC final rules, including vocabularies, code sets, nomenclatures, and terminologies. The vocabularies enable organizations to capture primary health data for internal use and external exchange to support the meaningful use objectives. Their use facilitates the interoperability of EHR systems as well as supporting the capture of clinical data, which can then be used with administrative/financial data to perform data analytics to improve the quality of patient care and address patient safety issues.

Developed by a group of AHIMA volunteers, the toolkit provides guidance to HIM professionals and the industry on vocabularies as defined by ARRA’s meaningful use criteria. It includes a table of standard vocabularies required for meaningful use, a case study that shares lessons learned from stage 1, and sample job descriptions to address the need for mapping professionals in the workplace.

The toolkit is free to AHIMA members. To access the full toolkit, available as a digital download, visit https://www.ahimastore.org/ProductDetailBooks.aspx?ProductID=16467. The following excerpt describes opportunities for HIM professionals working with meaningful use vocabularies.

 

Toolkit Excerpt

With the quick ramp-up by eligible professionals and eligible hospitals, HIM professionals must understand how vocabularies:

  1. Support the meaningful use objectives
  2. Provide:
  • a comprehensive data platform necessary for use in capturing, transmitting and reporting clinical information at the point of care
  • the most robust standards for use in meeting meaningful use requirements should be both seamless and efficient for the data to demonstrate meaningful use objectives, report associated measurements, and to potentially quality for incentives
  • the comprehensive foundation necessary for secondary data mapping; as objectives and timetables for implementing meaningful use stages are finalized, implementation of meaningful use vocabulary standards will facilitate seamless and efficient secondary data capture

 

  1. Facilitate efficient comprehension and organization of EHR data
  2. Supply the necessary standard vocabulary used in primary data capture internally in EHRs and support structured external communication for health information exchange, further paving the way for more comprehensive semantic interoperability

 

The final rules and regulations signal an ongoing commitment to interoperability and quality. If integrated health systems, hospitals, ancillary systems, and vendors are the engines through which users demonstrate meaningful use, the vocabularies are the fluids that run and support these engines.