Key Terms in Health Informatics: Essential Concepts Explained
School
Stark State College**We aren't endorsed by this school
Course
HIT 121
Subject
Nursing
Date
Dec 10, 2024
Pages
5
Uploaded by PresidentComputerParrot44
Chapter 5 Key Terms1.Axioms: page 128True statements. In health informatics, these are foundational truths or rulesused to build logical systems, such as the structure of clinical terminologies.2.Classification: page 124A clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings. A system of organizing information into categories for easier retrieval, often used for diagnoses, procedures, and conditions in health data (e.g., ICD-11).3.Clinical Terminology: page 124Are sets of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement. A standardized set of medical terms used by clinicians to document diagnoses, procedures, and other aspects of patient care.4.Code Set: page 124Is the accumulation of terms and codes for the exchange or storing of information. A predefined collection of codes used to represent clinical concepts, diagnoses, or procedures (e.g., ICD, CPT).5.Code System: page 124An accumulation of terms and codes for exchanging or storing information. A collection of codes with an associated meaning, used to ensure consistency indocumenting healthcare information (e.g., SNOMED CT).6.Common Clinical Data Set (CCDS): page 147Is the combination of these common sets of data types and elements and associated standards used across several certification criteria. A standardizedset of health information elements used in healthcare systems to improve interoperability and ensure consistent data exchange.7.Concepts: page 127A unique unit of knowledge or thought created by a unique combination of characteristics.
8.Data Set: page 145Is a list of recommended data elements with uniform definitions. A structuredcollection of related information, typically in tabular format, used for analysis or reference in healthcare.9.Derived Classification: page 139Is based on a reference classification such as ICD or ICF by adopting the reference classification structure and categories and providing additional detail or through rearrangement or aggregation of items from one or more reference classifications. A classification system that is created by deriving information from another primary classification, often used in healthcare statistics or reporting.10.Disability: page 138Is the umbrella term for impairments, activity limitations, and participation restrictions. Any limitation or impairment in physical, mental, or sensory functioning that affects an individual’s ability to perform certain activities or tasks.11.Extension Codes: page 137Starts with an X, adds detail to the stem code, and must be used with it. Theyare codes used to extend the meaning of primary codes in a system, providing additional specificity or detail in health records.12.Fully Specified Name (FSN): page 128Is the unique text assigned to a concept that completely describes it, and the synonym is an alternative way to describe the meaning of the concept in a specific language or dialect. A formal, unambiguous name of a concept in a terminology system, providing a complete and precise description.13.Functioning: page 138Is the umbrella term for Body Functions, Body Structures, Activities and Participation. It denotes the positive or neutral aspects of the interaction between the health condition and contextual factors.14.Granular Level: page 124Data consisting of small components or details at the lowest level. Refers to the level of detail or specificity within a dataset, terminology, or classification system.
15.Health Information Exchange (HIE): page 126Is when health information is electronically traded between providers and others with the same level of interoperability. The electronic sharing of health-related information among organizations in a standardized, secure manner to facilitate better healthcare delivery.16.International Classification of Diseases 11th Revision for Mortality and Morbidity Statistics (ICD-11-MMS): page 136Is a linearization of the ICD-11 foundation component. ICD-11-MMS will replace the World Health Organization (WHO)’s ICD-10. NCHS has not yet decided if a US specific linearization will be created as a possible replacementfor ICD-10-CM. A classification system for diseases and health conditions developed by the World Health Organization (WHO) for statistical reporting on mortality and morbidity.17.International Classification of Functioning, Disability, and Health (ICF): page 138A WHO framework for measuring health and disability at both individualand population levels.18.Linearization: page 136A subset of the foundation component; once created the subset becomes the Tabular list. The Tabular list is built for a use case, such as reporting mortalityand morbidity or primarycare. The process of arranging concepts from a complex classification system, such as ICD, into a simple, linear hierarchy for easier use and reporting.19.Morbidity: 133The state of being diseased includes illness, injury, or deviation from normal health. The state of having a disease or condition, or the rate of disease in a population.20.Nomenclature: page 124A recognized system of terms that follows pre-established naming conventions. A system of names or terms used to describe clinical concepts, diseases, or treatments in a standardized way.
21.Preferred Term (PT): page 129The description or name assigned to a concept that is used most in a clinical record or in literature for a specific language or dialect. The common or default name used to represent a concept in a terminology system, often more user-friendly than the fully specified name.22.Reference Terminology: pages126 and 127Is “a terminology designed to provide common semantics for diverse implementations”. A comprehensive, standardized system of terms that supports clinical data exchange and interoperability across systems (e.g., SNOMED CT).23.RxNorm Concept Unique Identifier (RXCUI): page 144A unique identifier used in RxNorm to represent a specific drug concept, ensuring precise drug-related communication.24.Semantic Interoperability: page 126Is the mutual understanding of the meaning of data exchanged between information systems. The ability of different systems to exchange data in a way that the meaning of the data is preserved and understood consistently.25.SNOMED CT Identifier (SCTID): page 127Is a unique integer that includes an item identifier, a partition identifier, and acheck-digit. It is a set of one or more axioms, or true statements, that serve as a starting point for further reasoning and arguments. A unique numerical identifier assigned to each concept in SNOMED CT, ensuring consistent and accurate data recording and exchange.26.Stem Codes: page 137Is a standalone code and can be a single entity or a combination of clinical detail (WHO 2018b). Basic codes used in classification systems can be extended with additional information to provide more specific detail.27.Unified Medical Language System (UMLS): page 147A comprehensive system of health-related terms, concepts, and relationships developed by the National Library of Medicine to support interoperability across multiple medical terminologies.28.Vocabulary: page 124
A list or collection of clinical words or phrases with their meanings. The set of terms and their definitions used within a particular field or system, such as medical terminologies or classification systems.