572 lines
30 KiB
HTML
572 lines
30 KiB
HTML
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<meta name="NLM.Contact.Email" content="oetweb@nih.gov">
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<title>Health Data Standards and Terminologies: A Tutorial</title>
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<body>
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<div class="container-fluid">
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<!-- NAVBAR -->
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<div class="row bg-primary">
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<nav class="navbar navbar-expand-md navbar-light bg-primary p-2">
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<div class="col-xl-3 col-lg-3 col-md-6 col-sm-6 col-9 pb-md-0 pb-2 ms-2">
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<a href="https://www.nlm.nih.gov/"><img src="img/NLM_White.png" class="img-fluid" alt="NLM logo"></a>
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<div class="collapse navbar-collapse" id="navbarSupportedContent">
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<ul class="navbar-nav mr-auto d-xs-flex d-sm-flex d-md-none d-lg-none d-xl-none" style="overflow-y: auto; height: calc(100vh - 68px); border-top: 0px solid #dee2e6;">
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href="#" id="navbarDropdown-1"
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role="button"
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data-bs-toggle="dropdown" data-bs-auto-close="false"
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aria-haspopup="true"
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aria-expanded="true">
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1: Functions and Types of Health Information Standards
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-1">
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<li><a class="dropdown-item" href="01-100.html" aria-current="true">Intro</a></li>
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<li><a class="dropdown-item active" href="01-200.html">The Electronic Health Record (EHR)</a></li>
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<li><a class="dropdown-item" href="01-300.html">Interoperability</a></li>
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<li><a class="dropdown-item" href="01-400.html">Health Data Standards</a></li>
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<li><a class="dropdown-item" href="01-500.html">Module 1 Knowledge Check</a></li>
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</ul>
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</li>
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<li class="nav-item dropdown">
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<a class="nav-link dropdown-toggle"
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-2" aria-haspopup="true" aria-expanded="false">
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2: Terminology Standards and Tools
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-2">
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<li><a class="dropdown-item" href="02-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="02-200.html">What are Terminology Standards?</a></li>
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<li><a class="dropdown-item" href="02-300.html">Characteristics of a Standardized Terminology</a></li>
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<li><a class="dropdown-item" href="02-400.html">ASTP/ONC and USCDI</a></li>
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<li><a class="dropdown-item dropdown-toggle" href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-Term" aria-haspopup="true" aria-expanded="false">Overview of Terminologies</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-Term">
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<li><a class="dropdown-item" href="02-500.html">Terminology Examples</a></li>
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<li><a class="dropdown-item" href="02-510.html">SNOMED CT</a></li>
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<li><a class="dropdown-item" href="02-520.html">RxNorm</a></li>
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<li><a class="dropdown-item" href="02-530.html">LOINC</a></li>
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<li><a class="dropdown-item" href="02-540.html">ICD</a></li>
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<li><a class="dropdown-item" href="02-550.html">CPT</a></li>
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<li><a class="dropdown-item" href="02-560.html">MeSH</a></li>
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<li><a class="dropdown-item" href="02-570.html">UCUM</a></li>
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</ul>
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</li>
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<li><a class="dropdown-item dropdown-toggle" href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-Tool" aria-haspopup="true" aria-expanded="false">Terminology Tools and Resources</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-Tool">
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<li><a class="dropdown-item" href="02-600.html">NLM Examples</a></li>
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<li><a class="dropdown-item" href="02-610.html">UMLS</a></li>
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<li><a class="dropdown-item" href="02-620.html">RxNav</a></li>
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<li><a class="dropdown-item" href="02-630.html">DailyMed</a></li>
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<li><a class="dropdown-item" href="02-640.html">VSAC</a></li>
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<li><a class="dropdown-item" href="02-650.html">AccessGUDID</a></li>
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<li><a class="dropdown-item" href="02-660.html">MedlinePlus Connect</a></li>
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<li><a class="dropdown-item" href="02-670.html">NIH Common Data Element Repository (CDE-R)</a></li>
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</ul>
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</li>
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<li><a class="dropdown-item" href="02-700.html">Module 2 Knowledge Check</a></li>
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</ul>
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</li>
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<li class="nav-item dropdown">
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<a class="nav-link dropdown-toggle"
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-3" aria-haspopup="true" aria-expanded="false">
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3: Exchange Standards
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-3">
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<li><a class="dropdown-item" href="03-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="03-200.html">HL7 International</a></li>
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<li><a class="dropdown-item" href="03-300.html">Version 2 (V2)</a></li>
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<li><a class="dropdown-item" href="03-400.html">Version 3 (V3)</a></li>
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<li><a class="dropdown-item" href="03-500.html">Clinical Document Architecture (CDA)</a></li>
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<li><a class="dropdown-item" href="03-600.html">Fast Healthcare Interoperability Resources (FHIR)</a></li>
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<li><a class="dropdown-item" href="03-700.html">Module 3 Knowledge Check</a></li>
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</ul>
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</li>
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<li class="nav-item dropdown">
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<a class="nav-link dropdown-toggle"
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-4" aria-haspopup="true" aria-expanded="false">
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4: Working Together - Revisiting Organizational Interoperability
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-3">
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<li><a class="dropdown-item" href="04-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="04-200.html">Implementation Guides</a></li>
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<li><a class="dropdown-item" href="04-300.html">Health Information Exchange (HIE)</a></li>
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<li><a class="dropdown-item" href="04-400.html">Government Programs</a></li>
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</ul>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="05-000.html">Closing</a>
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</li>
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<li><div class="dropdown-divider"></div></li>
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<li class="nav-item">
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<a class="nav-link" href="06-000.html">Additional Resources</a>
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<li class="nav-item">
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<a class="nav-link" href="nav.html">How to Navigate This Course</a>
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</li>
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</ul>
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</div>
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</nav>
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</div>
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<!-- / NAVBAR -->
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<!-- HEADER/BANNER -->
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<div class="row">
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<header class="bg-secondary p-3 truncate shadow" style="border-bottom: 1px solid #eee;">
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<strong>Health Data Standards and Terminologies</strong>
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<small class="text-muted">A Tutorial</small>
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</header>
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</div>
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<!-- / HEADER/BANNER -->
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<!-- / BREADCRUMB -->
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<div id="breadcrumb-div" class="container-fluid">
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<div class="breadcrumb-container">
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<ol class="breadcrumb mb-0" style="background-color: white;">
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<li class="breadcrumb-item">
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<a href="https://www.nlm.nih.gov/training.html" id="anch_29" target="_blank">Training & Outreach</a>
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</li>
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<li class="breadcrumb-item">
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<a href="https://learn.nlm.nih.gov/" id="anch_30" target="_blank">Learning Resources</a>
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</li>
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</ol>
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</nav>
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</div>
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</div>
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<!-- / BREADCRUMB -->
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<div class="row ms-1">
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<!-- LEFT COL - NAV SIDE -->
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<div class="col col-md-4 col-xl-3 d-none d-md-block p-0">
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<div id="sidebar" class="navbar navbar-light bg-light align-self-start">
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<ul class="nav nav-pills flex-column ps-2 pe-2" style="width: 100%;">
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<li class="nav-item">
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<a class="nav-link" href="index.html">Course Home</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-1">1: Functions and Types of Health Information Standards</a>
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<div id="collapse-item-1" class="collapse show">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="01-100.html">Intro</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link active" href="01-200.html">The Electronic Health Record (EHR)</a>
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</li>
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<li class="nav-item">
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||
<a class="nav-link" href="01-300.html">Interoperability</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="01-400.html">Health Data Standards</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="01-500.html">Module 1 Knowledge Check</a>
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</li>
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</ul>
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</div>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-2">2: Terminology Standards and Tools</a>
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<div id="collapse-item-2" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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||
<a class="nav-link" href="02-100.html">Intro</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-200.html">What are Terminology Standards?</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-300.html">Characteristics of a Standardized Terminology</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-400.html">ASTP/ONC and USCDI</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="#collapse-item-Term" data-bs-toggle="collapse">Overview of Terminologies</a>
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<div id="collapse-item-Term" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="02-500.html">Terminology Examples</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-510.html">SNOMED CT</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-520.html">RxNorm</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-530.html">LOINC</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-540.html">ICD</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-550.html">CPT</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-560.html">MeSH</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-570.html">UCUM</a>
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</li>
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</ul>
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</div>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="#collapse-item-Tool" data-bs-toggle="collapse">Terminology Tools and Resources</a>
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<div id="collapse-item-Tool" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="02-600.html">NLM Examples</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-610.html">UMLS</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-620.html">RxNav</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-630.html">DailyMed</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-640.html">VSAC</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-650.html">AccessGUDID</a>
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||
</li>
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||
<li class="nav-item">
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||
<a class="nav-link" href="02-660.html">MedlinePlus Connect</a>
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</li>
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||
<li class="nav-item">
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<a class="nav-link" href="02-670.html">NIH Common Data Element Repository (CDE-R)</a>
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||
</li>
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</ul>
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||
</div>
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||
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||
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</li>
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<li class="nav-item">
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||
<a class="nav-link" href="02-700.html">Module 2 Knowledge Check</a>
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||
</li>
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||
</ul>
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</div>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-3">3: Exchange Standards</a>
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<div id="collapse-item-3" class="collapse">
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||
<ul class="nav flex-column ps-3">
|
||
<li class="nav-item">
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||
<a class="nav-link" href="03-100.html">Intro</a>
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||
</li>
|
||
<li class="nav-item">
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||
<a class="nav-link" href="03-200.html">HL7 International</a>
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||
</li>
|
||
<li class="nav-item">
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||
<a class="nav-link" href="03-300.html">Version 2 (V2)</a>
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||
</li>
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||
<li class="nav-item">
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<a class="nav-link" href="03-400.html">Version 3 (V3)</a>
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||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="03-500.html">Clinical Document Architecture (CDA)</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="03-600.html">Fast Healthcare Interoperability Resources (FHIR)</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="03-700.html">Module 3 Knowledge Check</a>
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||
</li>
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||
</ul>
|
||
</div>
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||
</li>
|
||
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||
<li class="nav-item">
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||
<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-4">4: Working Together - Revisiting Organizational Interoperability</a>
|
||
<div id="collapse-item-4" class="collapse">
|
||
<ul class="nav flex-column ps-3">
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="04-100.html">Intro</a>
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||
</li>
|
||
<li class="nav-item">
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||
<a class="nav-link" href="04-200.html">Implementation Guides</a>
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||
</li>
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||
<li class="nav-item">
|
||
<a class="nav-link" href="04-300.html">Health Information Exchange (HIE)</a>
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||
</li>
|
||
<li class="nav-item">
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||
<a class="nav-link" href="04-400.html">Government Programs</a>
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||
</li>
|
||
</ul>
|
||
</div>
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||
</li>
|
||
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="05-000.html">Closing</a>
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</li>
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<li style="height: auto; line-height: 0;"><hr></li>
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<li class="nav-item">
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<a class="nav-link" href="06-000.html">Additional Resources</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="modal" data-bs-target="#navModal">How to Navigate This Course</a>
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</li>
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</ul>
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</div>
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</div>
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<!-- Modal -->
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<div class="modal fade" id="navModal" tabindex="-1" role="dialog" aria-labelledby="navModalLabel" aria-hidden="true">
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<div class="modal-header">
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<h5 class="modal-title" id="navModalLabel">How to Navigate This Course</h5>
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<button type="button" class="btn-close" data-bs-dismiss="modal" aria-label="Close">
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</button>
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<div class="modal-body">
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<p>
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There are a variety of ways you can navigate this course. You can:</p>
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<ul>
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<li>Click the Prev and Next buttons at the bottom of each page to move through the material.</li>
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<li>Use the main navigation with dropdown subsections featured on all pages.</li>
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<li>Use a combination of the above methods to explore the course contents.</li>
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</ul>
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<br>
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</div>
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<div class="modal-footer">
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<button type="button" class="btn btn-secondary" data-bs-dismiss="modal">Close</button>
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<!-- / LEFT COL - NAV SIDE -->
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<!-- RIGHT COL -->
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<div class="col col-md-8 col-xl-9 p-0 px-3">
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<!-- MAIN CONTENT AREA -->
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<div class="row justify-content-center">
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<h2>1: Functions and Types of Health Information Standards
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</h2>
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<h3>The Electronic Health Record (EHR)</h3>
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<img class="img-fluid float-end" style="height: 300px" src="img/EHR.png" alt="Electronic Health Record icon">
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<p>The <strong>electronic health record (EHR)</strong> is an electronic version of a patient’s medical history that helps make health information available in digital environments. For example, an EHR can make it possible for a physician to send a prescription directly to a pharmacist.</p>
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<p>The electronic record and the systems that enable record sharing allow healthcare providers and patients to connect health information from a variety of sources. This can provide a more complete view of a person’s health and can lead to better decision-making by both healthcare providers and patients.</p>
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<p>An EHR can be shared so that other systems can reliably use the content of the record and perform the tasks that they were built to perform. In addition to communicating patient health data for clinicians and patients, as the patient permits it, other organizations are also able to make use of the data that is present in this record.</p>
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<div class="alert alert-info shadow" role="alert">
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<p><strong>For example, the EHR is used for:</strong></p>
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<ul style="list-style: none;">
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<li><strong><i class="fas fa-check"></i> Clinical care</strong> - collecting and displaying relevant patient information to clinicians for decision-making and coordinating care among clinical staff.</li>
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<li><strong><i class="fas fa-check"></i> Billing</strong> - automating claims, coding, and charges.</li>
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<li><strong><i class="fas fa-check"></i> Quality management</strong> - enabling accuracy and clarity in record-keeping, and monitoring patterns in accidents and errors.</li>
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<li><strong><i class="fas fa-check"></i> Outcome reporting</strong> - generating reports on quality measures.</li>
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<li><strong><i class="fas fa-check"></i> Public health disease surveillance and reporting</strong> - aggregating information about test results and diagnoses to monitor population-level health events and indicators.</li>
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<h4>ASTP/ONC</h4>
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<p>To learn more about the EHR and its potential benefits, explore the <a href="https://www.healthit.gov/" title="https://www.healthit.gov/" target="_blank">website</a> of the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology (ASTP/ONC).</p>
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<p>ASTP/ONC is the “principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information” (from <a href="https://www.healthit.gov/topic/about-astponc" title="https://www.healthit.gov/topic/about-astponc" target="_blank">About ASTP/ONC | HealthIT.gov</a>).</p>
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<h4><i class="fas fa-puzzle-piece"></i> Activity</h4>
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<p>Explore the full extent of the ASTP/ONC website on your own, but to give you a sense of the information they provide, visit the "<a href="https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/what-are-electronic-health-records-ehrs" title="https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/what-are-electronic-health-records-ehrs" target="_blank">What Are Electronic Health Records (EHRs)?</a>" page and read about the benefits of the EHR.</p>
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</blockquote>
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<p>While the EHR has the potential to break down previously siloed information and facilitate better and more rigorous care, simply having a digital record does not mean that all the potential benefits of the EHR is immediately unlocked.</p>
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