In addition to provisions for code set standards for billing, HIPAA has its eye on patient medical record information (PMRI).
When providers do a procedure, give a drug or perform an operation, they send a bill that is now coded with CPT or ICD-9-CM. That is how they get paid.
However, billing codes do not reveal symptoms or a patient's ethnicity or things that were done that may not have to do with a particular drug or procedure.
Those things are important for physicians who want to know detailed clinical circumstances and how a patient responded, says John Neff, M.D., a pathologist and former chairman of the department of pathology at University of Tennessee Medical Center in Knoxville.
Enter clinical coding and Snomed Clinical Terms, created in the 1999 marriage of not-for-profit Snowmed International, developed by the College of American Pathology, and Clinical Terms Version 3, the code set created by James Read, M.D., that is used in Great Britain.
Snomed stands for Systemized Nomenclature of Medicine. Neff is chairman of the Snomed Authority, the board that controls the corporation. A precise coding system is key to populating an accurate and useful electronic medical record, according to Neff.
"You want specificity," he says. "For example, a hysterectomy with removal of the left or right ovary, or neither or both ovaries--those details have implications for ongoing care and need to be constructed in a very different way from billing terminology. Drafters of HIPAA recognized the difference from the very beginning."
The National Committee on Vital and Health Statistics, which advises HHS on health data, conducted hearings in late August in Washington, D.C., to begin determining criteria for the selection of PMRI terminology. The committee is expected to make its recommendations in about eight months. Noticeably absent are the HIPAA mandates and deadlines that pushed HHS to select its billing code set standards in October 2000.
Unifying clinical terminology will be a tall order, according to Dan Rode, vice president of policy and governmental affairs for the American Health Information Management Association.
"Terminology changes just in moving from one part of the country to another," Rode says. "Coding comes from the nomenclature of person who writes the order. Somebody is going to have to change.
"In dealing with Snomed, someone gets to pick off a menu instead of pulling it out of his head," Rode continues. "As things are standardized, a new generation of physicians will have a standard nomenclature, the older generation will say, 'look at this gain.'"
Major healthcare organizations and vendors, such as Kaiser Permanente and Cerner Corp., have committed to using Snomed. Other vendors either have committed or are currently evaluating Snomed as a core component of their EMRs.
"Caregivers must have the ability to interact with clinical information in familiar and intuitive ways," says Cerner physician executive Ian Chuang, M.D. "Cerner uses Snomed to provide structured flexibility in how clinical information is entered and viewed in different ways to support the preferences of a clinician, organization or venue of care, yet describe the same clinical concepts."
In one of the first agreements of its kind between an American medical society and a foreign government, the College of American Pathologists and Great Britain entered a three-year development deal in 1999 to merge Snomed terminology with the Read codes used in England. The result was the release of the first version of Snomed Clinical Terms this year.
The National Health Service now is conducting a formative evaluation of Snomed CT to provide feedback on any changes and improvements necessary for implementation. If successful, Snomed CT will become the mandated terminology for the NHS.
Because it is a true partnership, and because Great Britain already has invested more than 35 million pounds into the Read codes and additional resources in the development deal, Snomed CT will be made available to NHS providers without any fee.
"Competing in the standards world results in no standard," says pathologist and informaticist Kent Spackman, M.D., chair of the Snomed editorial board. "Collaboration results in a standard. We are very confident this whole process will yield what is needed to really make clinical terminology usable."
After the Centers for Disease Control and Prevention worked with Snomed on cancer and infectious disease reporting terminology, Spackman says the federal government recognized two years ago that it wanted a governmentwide Snomed license rather than piecemeal arrangements with different agencies. An agreement on the license has yet to be reached, but Snomed officials remain optimistic.
"Every single authority who has talked about healthcare in this country and our seeming inability to get it together says a major stumbling block is the lack of a uniform, controlled terminology that everybody uses and understands in the same way," Neff says. "That has driven Snomed for a long time."
"Some say, 'You're all about telling people what they have to say,'" Spackman adds. "No. Our goal is to reflect in a semantically correct way what people mean when they say things. Our job is to find out what people are saying and what they are meaning and to reflect that in the terminology."