For your selected organization (Salisbury, NC VA), examine the standards of the
applications the IT department uses. In your discussion include the importance of the
standards and any issues surrounding the standards (e.g., definitions consistent with other
organizations or across applications).
Standards in IT
Standards of Applications used in IT departments at Salisbury, NC, VA
Health data exchange and interoperability has been enhanced by health information
technology. To perform accurate data exchange, the information technology standards are used
to facilitate interoperability through a common code to encode health information. The standards
are perceived as the agreed health information “language” that can be interpreted accurately by a
multiple system (Depart of Veterans Affairs, 2012). When developing standards in this
healthcare facility, two main concepts are put into considerations including a) syntax-grammar
rules for the defined clinical language so that the electronic information can be exchanged
accurately with minimal deconstruction; and b) semantics- to ensure that the information
components are coded appropriately and their meaning can be understood (Moen & Mæland
Knudsen, 2013).
The standards used in this healthcare facility are guided by the Veterans Health
Administration (VHA) handbook which contains all the procedures of managing the clinical
coding process in the facility. The guiding framework consists of guidelines including the CPT
Assistant, Current Procedural Terminology (CPT), Diagnostic and Statistical Manual of Mental
Disorders (DSM) IV, Healthcare Common Procedure Coding System (HCPCS) and International
Classification of Disease Clinical Modification (ICD-CM). Physical observations, clinical
Standards in IT
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assessments and treatment plans are essential elements that require to be documented. There are
various data content standards that have been developed to create a framework of optimal health
and efficient exchange of information. This is actually vital with the increase focus on use of
Electronic Health records (Moen & Mæland Knudsen, 2013).
There is an increased need to create standards and definitions of individual terms in this
clinic, coupled with appropriate content standards in order to uniformly capture and collect
essential framing structures that define appropriate clinical concepts. This will facilitate effective
sending of patient information back and forth between the relevant stakeholders. At this health
care facility, the commonly used frameworks for standards in electronic health record system
includes National Council for Prescription Drug Programs (NCPDP), Continuity of Care
Record/Document, SNOMEDCT, Digital Imaging and Communications in Medicine (DICOM),
RxNorm, ICD-9-CM, HL7, HIPAA, Current Procedural Terminology (CPT) and ICD-10-
CM/PCS (Moen & Mæland Knudsen, 2013).
The use of these standards ensures meaningful performance, monitoring and outcomes
evaluation. In addition, the standards allows for consistent, evidence based care through clinical
decision support. The National Quality Forum’s Quality Data Model (QDM) offers potential for
precise, well defined, and universally accepted electronic measures that can be used for
comparison purposes and for improvement of care (Beaumont, 2000).
Advantages of the standards
The advantages of these standards are that they facilitate continuation of accuracy
through coding data that is reliable and accurate in planners, researchers and clinicians. In
addition, the standardized terminology facilitates easy documentation of every aspect of clinic
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including clinical problem, interventions as well as clinical outcome. Using standardized
terminologies aids in structuring of the data entry using a flexible expression that can be
understood by all- novice and experts (Moen & Mæland Knudsen, 2013). The standardized
terminologies aids in retrieval of coded data that have multiple attributes or have different levels
of specificity. This helps in establishing a common link to the clinical knowledge base, thereby
facilitating decision making process. Use of standardized language results into understanding the
various continuum of care from different physicians, clinical settings, languages or health care
systems. This is attributable to the fact that the various stakeholders involved can easily
exchange and apply health information in an appropriate way (Moen & Mæland Knudsen, 2013).
In addition, standardized terminology is used to identify and monitor the outcomes of
specific health needs or outcomes by pooling data from various resources. It supports the
auditing of quality services and in benchmarking processes that support research. Consequently,
it enables reporting of externally clinical and educational specified health statistics; which aids in
identification of individuals who needs proactive intervention (Moen & Mæland Knudsen,
2013).
Issues surrounding the standards
The main issue is keeping up the pace with the complex and dynamic standards. This
makes most of the staff at the healthcare facility to remain unfamiliar with the emerging types of
information being gathered or to understand where it fits in the health information standards
realm. Most people still don’t understand the relationship between the standard code used and
the major topics (Ajami & Arab-Chadegani, 2013).
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Therefore, it is important to prioritize and emphasize on health informatics in order to set
industry’s expectation. The Health Information Management staffs have a great responsibility to
play the role as advocates for application of information technology and in educating their fellow
colleagues. This is because standards contributes to longitudinal view of information technology
and calls for the unified expectations on defining of data, its storage and transfer to process,
identify and resolve service users needs. The ability to apply this information to drive
successful decisions in business intelligence is an emerging responsibility for HIM staff (Moen
& Mæland Knudsen, 2013).
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References
Ajami, S., & Arab-Chadegani, R. (2013). Barriers to implement Electronic Health Records
(EHRs). Materia Socio-Medica, 25(3), 213–215.
Beaumont, R. (2000). Database and Database Management Systems. Retrieved from
Fundamental Database Characteristics
Depart of Veterans Affairs. (2012). Health information management clinical coding program
procedures.