Coding and Messaging Systems for Women's Health Informatics

Coding and Messaging Systems for Women's Health Informatics

David Parry (Auckland University of Technology, New Zealand)
Copyright: © 2009 |Pages: 15
DOI: 10.4018/978-1-60566-078-3.ch003
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Abstract

Recording information about symptoms, observations, actions, and outcomes is a key task of health informatics. Standardization of records is vital if data is to be used by different groups, and transferred between organizations. Originally, coding focused on causes of death and other outcomes. Such systems include the international classification of diseases (ICD). However, more recently the need to allow communication between health organizations has encouraged the development of standards such as health level seven (HL7). Further work has focussed on vocabularies such as systematic nomenclature of medical terms (SNOMED), which allow standardised recording of any health-related information. Coded data is necessary to allow computers to assist in decision making and for audit purposes. With the rapid development of computer networks and the Internet, there has been a growing effort to include semantic information with computer data so that the meaning of the data can be bound to the data store. The chapter discusses these standards and the areas that are undergoing rapid development.
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Introduction

“We need three types of clinical information standards: document structuring standards; term lexicons; and ontologies”(Gardner, 2003)

Coding and messaging systems allow the standardisation and systemisation of information storage and transmission in healthcare. They allow the accurate and structured representation of information which can be used to impart a common understanding. The aim of this chapter is to introduce some of these systems along with the theory that underlies them and the uses to which they are put. These approaches are particularly important in women’s health informatics for a number of reasons:

  • In pregnancy it is common for women to be cared for by a number of healthcare professionals, and communication between them should be precise and efficient

  • Past outcomes and complications often have a great influence on the care plans for women in subsequent pregnancies, and this information is much more effective if standardised. Information recorded in previous pregnancies may be useful for risk prediction if presented in a suitable format.

  • Government agencies and healthcare organisations require accurate and extensive information in order to fulfil their information needs. Information relating to births has been collected for centuries, and improvement in morbidity and mortality can only be noted with standardised recording.

  • Funding and fee for service are often related to the case mix of the institutions providing the care.

  • Health Surveillance and audit of outcomes is particularly important for screening programmes and also to understand long-term trends such as the general rise in operative deliveries.

  • Research in the area of women’s health often requires re-examination of clinical records generated in the past. Accurate coding allows the selection of suitable records and patients for research studies as well as linkage between history, intervention and outcomes.

  • An exciting area of research is the development and use of decision support tools that use historical data to provide patients and clinicians with guidance concerning the likely outcome of clinical decisions and the natural history of disease. This sort of decision support is covered in more detail in Chapter XV.

For all these reasons, coding of clinical events, diagnoses and interventions is an important part of an information system designed to support women’s health.

At it’s heart, coding is a systematic and reproducible method of recording pertinent information for the improvement of management of healthcare. Messaging involves the transmission of healthcare information in a standardised and efficient format within and between information systems that are involved in the care of people.

In terms of system efficiency, coding can dramatically reduce the amount of data stored, and also increase the usefulness of this data for analysis. However the coding process is demanding and requires care and understanding of the principles of the coding system being used.

The next section of this chapter gives some background to the development of modern coding and messaging system. The main varieties of coding systems in use currently (ICD, READ, DRG) are described in the coding systems section. Messaging systems are then described including health level 7 (HL7) and Digital Imaging and Communications in Medicine (DICOM). More complex and complete systems for recording information including some controlled vocabularies such as SNOMED and ontologies are then described. Finally a discussion of the state of the art, and some future areas of development is contained in the final section.

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Editorial Advisory Board
Table of Contents
Foreword
Neil Pattison
Preface
Emma Parry, David Parry
Acknowledgment
Emma Parry, David Parry
Chapter 1
Peter Stone
Improving women’s health is a vital task for the world. The consequences of obstetric and gynecological disease are serious both for the women... Sample PDF
An Introduction to Women's Health and Informatics
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Chapter 2
Premila Fade
Principlism (derived from common sense morality) is the most common theory used within the healthcare sphere. The elements of this theory are... Sample PDF
Women's Health Informatics: The Ethical and Legal Issues
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Chapter 3
David Parry
Recording information about symptoms, observations, actions, and outcomes is a key task of health informatics. Standardization of records is vital... Sample PDF
Coding and Messaging Systems for Women's Health Informatics
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Chapter 4
Gareth Parry
Women’s health in primary care is a large part of the generalist’s practice. Information technology (IT) is now an integral part of the generalist’s... Sample PDF
Women's Health Informatics in the Primary Care Setting
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Chapter 5
Emma Parry
The seamless electronic health record is often hailed as the holy grail of health informatics. What is an electronic health record? This question is... Sample PDF
The Electronic Health Record to Support Women's Health
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Chapter 6
Graham Parry
Information technology and communication systems have made imaging in women’s health easier at many levels. There are now many commercial systems on... Sample PDF
Imaging and Communication Systems in Obstetrics and Gynecology
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Chapter 7
Emma Parry
Pregnancy is unique in medicine in providing a discrete event with a fixed end. It is well suited to data collection and statistical assessment.... Sample PDF
Statistical Measures in Maternity Care
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Chapter 8
Kiran Massey, Tara Morris, Robert M. Liston
Our ultimate goal as obstetric and neonatal care providers is to optimize care for mothers and their babies. As such, we need to identify practices... Sample PDF
Building Knowledge in Maternal and Infant Care
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Chapter 9
Malcolm Battin, David Knight, Carl Kuschel
Neonatal care is an extremely data-intensive activity. Physiological monitoring equipment is used extensively along with web-based information tools... Sample PDF
Informatics Applications in Neonatology
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Chapter 10
Jenny Westgate
During pregnancy the fetus requires an adequate supply of oxygen and clearance of carbon dioxide which is a waste product of metabolism. In fetal... Sample PDF
Computerizing the Cardiotocogram (CTG)
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Chapter 11
Liron Pantanowitz
Automation and emerging information technologies are being adopted by cytology laboratories around the world to augment Pap test screening and... Sample PDF
Computer Assisted Cervical Cytology
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Chapter 12
Laurie Elit, Susan Bondy, Michael Fung-Kee-Fung, Prafull Ghatage, Tien Le, Barry Rosen, Bohdan Sadovy
Ovarian cancer affects 2,400 women annually in Canada with a case fatality ratio of 0.70. There are several practice guidelines that indicate women... Sample PDF
Informatics and Ovarian Cancer Care
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Chapter 13
Jamila Abuidhail
Information and communication technologies include computers, telecommunication, digital networks, and television. Using informatics in healthcare... Sample PDF
Women's Health and Health Informatics: Perinatal Care Health Education
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Chapter 14
Shona Kirtley
In an age where health professionals lead very busy working lives, electronic information sources provide ease of access to vast amounts of health... Sample PDF
Electronic Information Sources for Women's Health Knowledge for Professionals
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Chapter 15
David Parry
Decision analysis techniques attempt to utilize mathematical data about outcomes and preferences to help people make optimal decisions. The... Sample PDF
Computerised Decision Support for Women's Health Informatics
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Chapter 16
Michelle Brear
The influence of organizational factors on the success of informatics interventions in healthcare has been clearly demonstrated. This health... Sample PDF
Organizational Factors: Their Role in Health Informatics Implementation
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Chapter 17
Josipa Kern
When things go well then often it is because they conform to standards (ISO, 2005). According to the Oxford Dictionary of Modern English, there is a... Sample PDF
Standardization in Health and Medical Informatics
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Chapter 18
Elske Ammenwerth, Stefan Gräber, Thomas Bürkle, Carola Iller
This chapter summarizes the problems and challenges which occur when health information systems are evaluated. The main problem areas presented are... Sample PDF
Evaluation of Health Information Systems: Challenges and Approaches
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Chapter 19
Pirkko Nykänen
eHealth refers to use of information and communication technologies to improve or enable health and healthcare. eHealth broadens the scope of health... Sample PDF
eHealth Systems, Their Use and Visions for the Future
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Chapter 20
Nilmini Wickramasinghe, Santosh Misra, Arnold Jenkins, Douglas R. Vogel
Superior access, quality and value of healthcare services has become a national priority for healthcare to combat the exponentially increasing costs... Sample PDF
The Competitive Forces Facing E-Health
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About the Contributors