The 2018 AHIMA convention session, “Industry Standards: The Big Three Every HIM Professional Should Know and Value,” will take place Tuesday, September 25 from 3:30-4:15 p.m. in Lincoln Ballroom E-H of the Miami Convention Center. The Journal of AHIMA recently spoke with presenter Cheryl Mason, MSHI, for a preview of her session.
Journal of AHIMA: What are you hoping members will take away from your session?
Mason: My hope is that this presentation will equip today’s HIM professionals with insights into the “Big Three” terminology standards: SNOMED CT, LOINC, and RxNorm. They will learn why these standards are important for clinical care, data capture and the bottom line. Perhaps most importantly, I will advocate for HIM’s role in implementing and maintaining these important standards. I will share best-practice strategies for optimizing internal workflows aimed at ongoing management of the big three clinical terminologies.
Journal of AHIMA: What should HIM professionals be focusing on now in regards to “the Big Three?”
Mason: As stewards of the medical record and advocates for accurate representation of a patient’s story, the HIM professional needs to be aware of how and why the big three terminologies are used in telling that story. Where do they interact with the patient record and how can they be used to impact patient outcomes? For instance, SNOMED CT is the most comprehensive, multilingual, clinical terminology in the world, encompassing more than 300,000 clinical concepts. SNOMED CT also contains terms, synonyms, and relationships that further define the meaning of each concept. Healthcare organizations must stay abreast of regular updates to this complex terminology in order to circumvent negative downstream impact.
Terminology is core to everything in healthcare—from procedures to results to diagnoses. While terminology management is not the endgame, it is foundational to accurate and complete patient care, data analytics, and registry and quality measures reporting. Lack of a common clinical vocabulary necessitates that maintenance of clinical standards like SNOMED CT, LOINC, and RxNorm be prioritized to ensure the meaning of the clinical data is unambiguous.
Journal of AHIMA: Can you talk about the role of the standards SNOMED CT, LOINC, and RxNorm?
Mason: To exchange and use all the data being collected in healthcare today, it all needs to be represented using widely accepted terminology standards. In the age of reduced provider margins, quality reporting, analytics, population health, and a mobile patient population, we simply must ensure standardization of the way we represent a patient’s story. We can no longer rely on individual physician vernacular and unstructured data within our clinical data repositories. The big three standard terminologies help us as an industry better represent the patient story, aggregate information for analytics and population health, and affect change in the health of individuals and populations while addressing the high cost of healthcare.
Journal of AHIMA: How should AHIMA members be preparing for changes in industry standards?
Mason: Standards bodies update their terminologies on different timelines and in different formats from one another. While HIM is good at understanding, monitoring for, and implementing changes in the standard billing classification systems (CPT, ICD-10, and HCPCS), they must also advocate for data governance around the more robust clinical terminologies like RxNorm, LOINC, and SNOMED CT. As the stewards for the medical record, it is imperative that HIM professionals have a seat at the table of data governance for their organizations. This presentation arms the HIM professional with a framework to engage in those conversations effectively.
Journal of AHIMA: How can attendees start incorporating the lessons from your session in their organization right away?
Mason: One of the objectives of this presentation is to design a best-practice terminology management model that leverages information governance and automation. Information presented in this session will be practical and can be used to immediately impact a reference data management strategy.
Journal of AHIMA: Is there anything else you would like members to know about your session or data analytics in general?
Mason: There is a lot riding on the healthcare industry’s ability to advance interoperability. The success of ongoing investments in business intelligence, data governance, analytics, quality measurement, population health and risk sharing all rely heavily on information-sharing capabilities between stakeholders.
Cheryl Mason, MSHI, is the director of content and informatics at Wolters Kluwer in Denver, CO.