A comparison between a SNOMED CT problem list and the ICD-10-CM/PCS HIPAA code sets.

In 2013 the United States will convert from the use of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the use of the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). This study compares the approximately 5,000 terms in the July 2009 Clinical Observations Recording and Encoding (CORE) Problem List subset of the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) terminology produced by the National Library of Medicine with terms found in the January 2009 versions of ICD-10-CM/PCS. The comparison was done by a single individual and used the internally defined concepts of "Exact," "Inexact," "Model" (one SNOMED CT term to many ICD-10-CM/PCS terms), "Not Elsewhere Classified," "Not Otherwise Specified," "Synonym," and "Not Found" to classify the CORE Problem List terms according to the quality of the match. Among the CORE Problem List terms, 6.0 percent were not found in ICD-10-CM/PCS, and 69.1 percent had equivalent ICD-10-CM/PCS terms. The 13.0 percent of terms classified as "Inexact" could also be used directly assuming some acceptable loss of clinical precision. The 11.9 percent of terms classified as "Model" represent differences that require rule-based mapping. The results of this study suggest that ICD-10-CM/PCS meets the intended design goal of increased clinical precision but studies are needed to precisely define the depth of coverage.

International classification of diseases, 10th edition, clinical modification and procedure coding system: descriptive overview of the next generation HIPAA code sets.

Described are the changes to ICD-10-CM and PCS and potential challenges regarding their use in the US for financial and administrative transaction coding under HIPAA in 2013. Using author constructed derivative databases for ICD-10-CM and PCS it was found that ICD-10-CM's overall term content is seven times larger than ICD-9-CM: only 3.2 times larger in those chapters describing disease or symptoms, but 14.1 times larger in injury and cause sections. A new multi-axial approach ICD-10-PCS increased size 18-fold from its prior version. New ICD-10-CM and PCS reflect a corresponding improvement in specificity and content. The forthcoming required national switch to these new administrative codes, coupled with nearly simultaneous widespread introduction of clinical systems and terminologies, requires substantial changes in US administrative systems. Through coordination of terminologies, the systems using them, and healthcare objectives, we can maximize the improvement achieved and engender beneficial data reuse for multiple purposes, with minimal transformations.

OIDs: how can I express you? Let me count the ways.

An object identifier (OID) has a central utility in providing a traceable source for the meaning of an identifier appearing in a cross-system communication. The views in this paper illustrate the problems with using the present OID registration system as a reliable source for the identifier, the confusion that the use of an OID introduces in messages, and the redundancy that the OID introduces at the expense of increased message size and no new content. In promoting clearly defined cross-system communication identifiers, Health Level 7 developed a standard that required use of OIDs outside of network addressing. This standard and its propagation by others may have paradoxically added more confusion than clarity.

Introduction of a hierarchy to LOINC to facilitate public health reporting.

Public health reporting of laboratory results requires unambiguous identification of the test performed and the result observed. Some laboratories are currently using Logical Observation Identifier Names and Codes (LOINC) for the electronic reporting of laboratory tests and their results to public health departments. Initial use revealed inconsistent identification and use of LOINC concepts by laboratories and public health agencies and an inability to systematically extend, for public health use, the tables when adding new concepts. We applied simple, logical rules to existing LOINC concepts to facilitate the creation of a hierarchy of concepts and to allow the identification and specification of appropriate terms for public health reporting and subsequent data aggregation. The hierarchy also allows the systematic addition of new concepts further supporting public health reporting. Application of the hierarchy is illustrated by using all laboratory LOINC concepts assigned to the subset of microbiology test types (CLASS MICRO).

Practice patterns of testing waived under the clinical laboratory improvement amendments.

OBJECTIVES: To determine operational practices in laboratories operating under a Certificate of Wavier (waived laboratories), or equivalent, under the Clinical Laboratory Improvements Amendments (CLIA) of 1988 when performing tests designated as having an insignificant risk of an erroneous result (ie, waived tests). METHODS: Waived laboratories that were part of the Centers for Disease Control and Prevention Laboratory Sentinel Monitoring Network project in the states of Arkansas, New York, and Washington were surveyed about their quality control (QC) and quality assurances (QA) practices when performing waived testing. Arkansas and Washington sent out similar questionnaires, whereas on-site surveys were conducted in New York. The survey in Arkansas and Washington also included nonwaived laboratories. The New York visits were designed to pilot test a regulatory inspection program for limited testing sites, which, in New York, are roughly equivalent to laboratories operating under a CLIA Certificate of Wavier and/or Provider-Performed Microscopy but are generally not located in physicians' offices. Laboratories visited in New York were selected from a list of limited testing sites and were representative of that population. RESULTS: Arkansas received responses from 211 facilities (37% response rate), of which 38% had Certificates of Waiver. Washington received responses from 190 waived laboratories (71% response rate) and from 116 nonwaived laboratories (32% response rate). In New York, 607 of the 2751 limited testing laboratories were visited. Reporting laboratories in all 3 states most frequently performed testing for glucose, urinalysis, urine human chorionic gonadotropin, occult blood, and group A Streptococcus antigen, although other waived tests were performed less frequently. Washington found that 57% of waived laboratories followed manufacturers' QC requirements. Arkansas found that 58% of laboratories doing waived tests that required liquid controls performed these controls, and 59% performing waived testing requiring electronic controls used these controls. In New York, 68% of the laboratories complied with the manufacturer's QC requirements for a variety of tests. Being accredited by an external organization or affiliated with a more complex laboratory improved compliance. Nonwaived laboratories in Washington and Arkansas complied with manufacturer's instructions at a higher rate than did waived laboratories. Similar deficiencies in following CLIA requirements were found in other areas of laboratory operation. CONCLUSIONS: Just more than half of waived laboratories in 3 diverse states follow manufacturer's instructions for recommended QC and QA. These instructions help ensure that the test will produce results that have an insignificant chance of an error. Although we did not study the impact of this and other findings on patient care, the results show that imposing good laboratory practices by regulation alone was insufficient to ensure quality laboratory results in any location evaluated. A system that can continually provide accessible education on laboratory practices, coupled with new thoughts on the regulatory environment, is in order.

Laboratory critical values policies and procedures: a college of American Pathologists Q-Probes Study in 623 institutions.

CONTEXT: Critical values lists have been used for many years to decide when to notify physicians and other caregivers of potentially life-threatening situations; however, these lists have not been studied widely. OBJECTIVES: To investigate critical values lists in institutions participating in the College of American Pathologists Q-Probes program and to provide suggestions for improvement. SETTING: A total of 623 institutions voluntarily participating in the Q-Probes program. DESIGN: A multipart study in which participants responded to information from preprinted lists, collected information about current practices, completed a questionnaire, monitored critical values calls, reviewed patients' medical records, and surveyed nursing supervisors and physicians about critical values. MAIN OUTCOME MEASURES: Defining critical values systems, including lists, personnel, costs, processes, usefulness, and related medical outcomes. RESULTS: Critical values lists were determined for routine chemistry and hematology analytes and were found to vary widely among participants. In contrast, more than 95% of participants reported positive blood cultures, cerebrospinal fluid cultures, and toxic therapeutic drug levels as critical values. Based on more than 13 000 critical values, participants' data showed that most critical values reports (92.8%) were made by the person who performed the test, and that 65% of reports for inpatients were received by nurses. For outpatients, physicians' office staff received the largest percentage (40%) of reports. The majority of participants (71.4%) had no policy on how repeat critical calls should be handled. On average, completion of notification required about 6 minutes for inpatients and 14 minutes for outpatients. Slightly greater than 5% of critical value telephone calls were abandoned, with the largest percentage abandoned for outpatients. More than 45% of critical values were unexpected, and 65% resulted in a change in therapy. Although only 20.8% of 2301 nursing supervisors thought critical values lists were helpful, 94.9% of 514 physicians found critical values lists valuable. CONCLUSIONS: Critical values systems were medically important, highly variable, but also costly practices for participants. We propose a number of recommendations for improvement, including that the critical values list should be approved by the medical staff, each laboratory should develop a written policy for handling initial and repeat critical values reports, a foolproof policy should be established to report results from calls abandoned, and efforts at automating the process should become widespread.

Routine outpatient laboratory test turnaround times and practice patterns: a College of American Pathologists Q-Probes study.

OBJECTIVES: To determine baseline parameters for routine outpatient test turnaround time (TAT), to identify influential factors, and to study the impact of managed care on this testing. METHOD: Using forms supplied by the College of American Pathologists Q-Probes program, laboratories conducted a self-directed study of routine outpatient TATs over a 4-week period. Data requested included various times of day associated with the collection, laboratory receipt, and result verification of specimens, as well as details on the drawing location and ordering and delivery methods for up to 3 tests, namely, a complete blood cell count (CBC), biochemical profile, or thyrotropin test. For the CBC, an indication was requested if a manual differential was performed. Additionally, practice-related questions were asked, including several about whether the laboratory was associated with a managed care organization (MCO). The main outcome measures included the components of the TAT process and related factors.Participants.-Six hundred nineteen laboratories from those enrolled in the 1997 College of American Pathologists Q-Probes program. RESULTS: Data were submitted by 614 participants, most US hospitals, and represented 30 240 CBCs, 25 683 biochemical profiles, and 14 801 thyrotropins. Collection to verification TATs increased for specimens received later in the day for all analytes, but the magnitude of the increase was greatest for thyrotropin. Collection to laboratory receipt TAT was similar for all analytes, but the time and distribution increased with time of day. Testing time (receipt to verification) was similar for the CBC and biochemical profile, but was greatly increased for thyrotropin. Most participants tested the CBC and the biochemical profile as they arrived, but many delayed testing for thyrotropin. Most (70%) outpatient specimens were collected within the institution; only about 10% came from local physicians' offices. A median 46.7% of hospital testing involved outpatients. Only 10% of laboratories operated under an MCO; these laboratories reported a median of 45% of specimens coming from their MCO. Being associated with an MCO increased TAT for the CBC and biochemical profile. CONCLUSIONS: Outpatient testing comprises about half of all hospital testing, yet systems are not optimized. Preanalytic TAT increases during the day, which indicates increasing delays in the collection and transport stages. Imposition of a test schedule on thyrotropin results in a delay pattern that is very different from the CBC and biochemical profile, which are tested on arrival. A laboratory's association with an MCO had a weak impact on TAT.