Embracing the International Agenda... Nutrition care processes, outcomes and standardised terminology

Transcription

1 Embracing the International Agenda... Nutrition care processes, outcomes and standardised terminology Introduction to Coding, Classifications and Terminologies Ingrid Darnley BDA Policy officer Clinical Quality

2 Clinical Classifications Systematic arrangement of like entities based on differing characteristics, Classifications are relatively or totally static e.g. ICD-10 Classification (ICD) is the NHS mandatory clinical classification of causes of morbidity and mortality for all inpatient episodes and attendances, these are coded to ICD-10 OPCS-4 is the NHS mandatory clinical classification of NHS Interventions and Procedures for all inpatient episodes and attendances, these are coded to OPCS-4

3 Clinical coding The translation of clinical terminology, as recorded by the clinician in the patient record, into a coded format Coded clinical data (generated from classifications OPCS-4 and ICD-10) is grouped to meet the reporting structure of Payment by Results to ensure Hospitals are paid accurately for activity. All English trusts use a fixed price tariff for specific treatments. NHS clinical coding systems currently concentrates on acute providers and future work for the DH Connecting for Health will concentrate on development of codes for outpatients and community The NHS clinical classifications ICD-10 and OPS-4 are not intended or designed for point of care recording by a clinician.

4 WHAT IS A TERMINOLOGY? A terminology is a list of things which belong to the same language or family, e.g. plants, tumours and diseases. Terminologies are dynamic, expanding or being refined as necessary A terminology is arranged in a logical manner and can be updated on a regular basis. A terminology such as Snomed CT is used directly by clinicians for patient information recording.

5 Benefits of using Clinical Terminology Reduces the implicit contextual meaning in clinical statements. This increases the chance of a statement being correctly understood by other clinical staff. The ability to search records for clinical information is dependent on using a structured terminology. Identification of patients who match a given set of criteria, to identify patients who fall into a given category the clinical information in the patient s record must be recorded using a terminology. Outcome analysis Whilst there is an increasing focus on evidence based medicine in clinical practice today, there is little usable information to base that evidence on. Public health benefit to patients that will arise from the development of a good evidence base from encoded (aggregated) clinical data.

6 SNOMED CT The Systematized Nomenclature of Medicine (Clinical Terms) SNOMED CT was developed from a merger of Clinical Terms (Read Codes) and SNOMED Reference Terms. The International Health Terminology Standards Development Organisation (IHTSDO) is an international not-for-profit organization which owns and administers the rights to SNOMED CT and related terminology standards. Snomed is the data standard for use by the NHS and NHS system suppliers approved by ISB to support interoperability of electronic health records. SNOMED-CT is designed for use in electronic, not paper-based, health record systems and the content of SNOMED CT is primarily intended to be used for patient information recording.

7 Characteristics of Snomed CT (terminology) vs ICD-10 and OPCS (classifications) Together, terminologies, such as SNOMED-CT, and classification systems, such as ICD- 10 and ICD-10, complement each other and provide the common clinical language necessary for interoperability and the effective sharing of clinical data.

8 Dietetics and Snomed CT Snomed CT does not contain a nutrition and dietetics subset. The BDA is committed to developing this for UK practice. We have the support of DH Connecting for Health to do this. and this work is just starting. The subset will include the most commonly used dietetic terms, tools and resources. This work will be informed by the work of Vera Todorovic in developing local dietetic templates. Identification and incorporation of any UK Synonyms into Snomed Requires ongoing support, feedback, suggestions and endorsement of BDA members, both now and on an ongoing basis. Once the subset has been developed, formally evaluated and adopted by SnomedCT the terms will be available for the use of all health professions. The BDA must build robust internal processes for reviewing the subset; this will be an ongoing professional commitment and responsibility for the BDA.

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10 BDA Model and Process for Nutrition and Dietetic Practice (2012) The Process can be used for Structuring dietetic records. Developing packages of care, based on diagnoses. Developing clinical reasoning. Identifying barriers to improving outcomes. Teaching students. The Process is adapted from the American Academy of Nutrition and Dietetics Nutrition Care process (NCP). The International Dietetics and Nutrition Terminology (IDNT) is the standardised language used to support the nutrition care process

11 BDA adoption of the International Dietetic and Nutrition Terminology The BDA has approved the adoption of the International Dietetic and Nutrition Terminology as the preferred basis for use in electronic records. The BDA briefing (2012) deldieteticpractice/bda_briefingrecordstandards.pdf outlines the links between the Process, IDNT and the development of records (including electronic) and standards for records

12 International Dietetic and Nutrition Terminology IDNT is a specific dietetic TERMINOLOGY and provides a standard set of core nutrition care terms and definitions for the four steps of the ADA nutrition care process (NCP): assessment, nutrition diagnosis, interventions and monitoring/ evaluation. Use of IDNT promotes uniform documentation of nutrition care provided, enables differentiation of the type and amount of nutrition care provided and provides a basis for linking nutrition care activities with actual or predicted outcomes. IDNT needs to gain international dietetic involvement and agreement of terms to meet the Snomed requirements for the cross mapping of IDNT into SnomedCT. The BDA is an active participant in this work through the BDA Office. The IDNT Assessment terms will need some restructuring to fit in with how assessment is taught by dietetic educators in the UK. The IDNT Intervention terms needs discussion and debate and will need to be expanded to include medicines, lifestyle and coordination of care to reflect UK dietetic practice.

13 And for more information.. The next two speakers. Information Services Division (NHS Scotland) :Terminology Services and Clinical Coding Services/Coding-and-Terminology-Systems/ Academy of Nutrition and Dietetics BDA Informatics and record standards work stream Sue Kellie and Ingrid Darnley at