Pediatric Informatics: Computer Applications in Child Health (Health ...

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430 G.R. Kim and S.T. Rosenbloom Coding for service documentation and reimbursement: � Medical diagnosis: International Classification of Diseases (ICD9 – CM, ICD-10) � Psychiatric diagnosis: Diagnostic and Statistical Manual of Mental Disorders (DSM IV) � Evaluation, management and procedures: Common Procedural Terminology (CPT) � Documentation and study of processes and outcomes for quality improvement: Nursing Intervention and Outcomes Classifications (NIC, NOC) � North American Nursing Diagnosis Association (NANDA) � Ordering and tracking items used in medical work � Drug classes, specific drugs, their forms, amounts, and packaged doses (RxNorm, Multum, FirstDataBank, Micromedex) Laboratory and imaging test names, specifications, result units and normal ranges (Logical observations indicators names and codes (LOINC)) Medical equipment (Food and Drug Administration Product Code Classification) Indexing, retrieval of and linkage to published medical knowledge � Medical Subject Headings (MeSH) for medical journal articles � CINAHL Subject Headings for nursing journal articles � Thesaurus of Psychological Index Terms for psychology journal articles Locating patient-specific data � Descriptive data: SNOMED CT � Health Level Seven Natural language processing (and applications) � The Unified Medical Language System (and MetaMap) � The Medical Entities Dictionary (and MEDLEE) � SNOMED CT (and Lingologix) Clinical documentation � ® 3 SNOMED CT (used in Kaiser Permanente’s HealthConnect EHR, among others) � ® Medcin (used in the Department of Defense’s Armed Forces Health Longitudinal Technology Application (AHLTA) EHR4 ) � Medical Entities Dictionary (used at New York Presbyterian Hospital The central importance of terminologies in US health care was reinforced in 2005 with the development of the Federal Consolidated Health Informatics (CHI) initiative (a part of the eGovernment Business portfolio) which adopted a set of existing terminologies (and identified gaps) for use in electronic exchange of clinical information within specified health domains by the US Federal health enterprise, its clients and partner entities (see Table 33.1). 6 33.2.2 Implementations Technical requirements for well-constructed terminologies in biomedicine have been articulated. 8 These requirements include formal definitions, sufficient scope 5 )
33 The Case for a Pediatric Terminology 431 Table 33.1 Consolidated health informatics terminology standards 7 Domain Terminology standard Anatomy National Cancer Institute (NCI) Metathesaurus, SNOMED CT Diagnosis/Problem Lists Laboratory Results Standardized Nomenclature of Medicine Clinical Terms (SNOMED CT) Non-Laboratory Interventions/ Procedures Nursing Demographics Immunizations Clinical Encounters Health Level Seven (HL7) Text Based Reports Units Laboratory Result Names Logical Observations Indicators Names and Codes (LOINC) Laboratory Test Order Names Genes Human Gene Nomenclature (HUGN) Environmental Protection Agency’s (EPA) Chemicals Substance Registry System (SRS) Medications: Food and Drug Administration’s (FDA) Active Ingredients Unique Ingredient Identifier (UNII) Clinical Drugs National Library of Medicine (NLM) RxNORM Drug Classifications National Drug File Reference Terminology (NDF-RT) Food and Drug Administration’s (FDA) Drug Product National Drug Code (NDC) Product Name/Code Manufactured Dosage Form Food and Drug Administration (FDA) Center for Drug Evaluation and Research (CDER) Package Data Standards Manual Special Populations Health Level Seven Version 2.x Logical Observations Indicators Names and Codes (LOINC) Structured Product Label Clinical Structured Product Label (SPL) HIPAA Approved Code Sets Health Insurance Portability and Accountability Act (HIPAA) transactions and code sets Supplies History & Physical Population Health Disability No current standards Physiology Proteins Multimedia and granularity of concepts to describe entities and events within a domain (to the extent and detail needed) and reusability. Different terminologies implementations include: Dictionaries, catalogs: structured collection of terms that may be related to objects, with attributes (e.g., drug formulary with generic and trade names, dose, and route information)
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Health Informatics (formerly Comput
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Editors Christoph U. Lehmann George
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vi Series Preface changes to both t
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viii Foreword This text will prove
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x Preface financial investment and
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How to Use This book This book is t
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xvi Contents 9 Pediatric Care, Safe
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xviii Contents Part VII A Vision an
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xx Contributors Donna M. D’Alessa
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xxii Contributors Christoph U. Lehm
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xxiv Contributors Mark M. Simonian,
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4 G.R. Kim pharmacy, medical educat
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6 K.B. Johnson and G.R. Kim Deaths
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8 K.B. Johnson and G.R. Kim 2.4.1 I
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10 K.B. Johnson and G.R. Kim 2.4.3
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12 K.B. Johnson and G.R. Kim Educat
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14 K.B. Johnson and G.R. Kim 2.6 Co
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Chapter 3 Core Pediatric Data Kevin
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3 Core Pediatric Data 21 3.3 Pediat
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3 Core Pediatric Data 23 3.6 Pediat
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Chapter 4 Neonatal Care and Data De
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4 Neonatal Care and Data 27 Essenti
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4 Neonatal Care and Data 29 4.3 The
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4 Neonatal Care and Data 31 some ma
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4 Neonatal Care and Data 33 Measure
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4 Neonatal Care and Data 35 4.5.2.4
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4 Neonatal Care and Data 37 4.6.3 I
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4 Neonatal Care and Data 39 4.7.2.2
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4 Neonatal Care and Data 41 Availab
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44 D.M.N. Paperny Tasks related to
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46 D.M.N. Paperny Behavioral risk d
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48 D.M.N. Paperny for outside ancil
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50 D.M.N. Paperny Video reinforceme
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52 D.M.N. Paperny 3. Litzelman DK,
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Chapter 6 Children with Development
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6 Children with Developmental Disor
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Chapter 7 Pediatric Emergency and P
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7 Pediatric Emergency and Pediatric
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84 W.H. Drummond et al. A recovery
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86 W.H. Drummond et al. 8.2.2 Forma
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88 W.H. Drummond et al. 8.2.2.1 Sys
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90 W.H. Drummond et al. The multidi
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92 W.H. Drummond et al. noise overl
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94 W.H. Drummond et al. needs requi
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96 W.H. Drummond et al. Children’
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98 W.H. Drummond et al. After the P
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100 W.H. Drummond et al. Table 8.2
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104 W.H. Drummond et al. when to su
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106 W.H. Drummond et al. It is crit
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108 W.H. Drummond et al. traditiona
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110 W.H. Drummond et al. and human
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112 W.H. Drummond et al. blood prod
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116 W.H. Drummond et al. 35. Collin
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Chapter 9 Pediatric Care, Safety, a
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9 Pediatric Care, Safety, and Stand
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134 D.M. D’Alessandro The EBM pro
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136 D.M. D’Alessandro 10.4 Pragma
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138 D.M. D’Alessandro 4. Case ser
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140 D.M. D’Alessandro Ontario, BC
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142 D.M. D’Alessandro Table 10.1
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144 D.M. D’Alessandro Children ar
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146 D.M. D’Alessandro 17. Ely JW,
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Chapter 11 Clinical Practice Guidel
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11 Clinical Practice Guidelines: Su
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162 M.J. Feldman in patients withou
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164 M.J. Feldman The art of medicin
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166 M.J. Feldman important design g
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168 M.J. Feldman Incorrect or missi
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170 M.J. Feldman Fig. 12.4 GIDEON D
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172 M.J. Feldman system or etiology
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174 M.J. Feldman ED-12: “Practica
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176 M.J. Feldman Fig. 12.7 DXplain:
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178 M.J. Feldman For GIDEON: Rabies
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180 M.J. Feldman KB on infectious d
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182 M.J. Feldman 4. Johnson KB, Fel
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Chapter 13 Managing Pediatric Knowl
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13 Managing Pediatric Knowledge Res
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Chapter 14 Supporting Continuing Pe
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14 Supporting Continuing Pediatric
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14 Supporting Continuing Pediatric
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Chapter 15 Pediatric Care Coordinat
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15 Pediatric Care Coordination: The
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Chapter 16 Prioritizing Pediatric I
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16 Prioritizing Pediatric Investmen
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Chapter 17 Aligning Pediatric Ambul
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17 Aligning Pediatric Ambulatory Ne
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258 G.R. Kim and C.U. Lehmann Elect
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260 G.R. Kim and C.U. Lehmann 18.2.
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262 G.R. Kim and C.U. Lehmann There
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264 G.R. Kim and C.U. Lehmann 13. C
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266 K.B. Johnson and C.G.M. Weigle
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280 C. Sable et al. computer for la
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282 C. Sable et al. Table 20.3 Tele
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284 C. Sable et al. without increas
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286 C. Sable et al. Fig. 20.1b Wash
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288 C. Sable et al. prior to case d
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290 C. Sable et al. presence of con
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292 C. Sable et al. 17. Sable C, Ro
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294 A.E. Zuckerman and G.R. Kim 21.
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296 A.E. Zuckerman and G.R. Kim �
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Chapter 22 Privacy Issues David M.N
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22 Privacy Issues 305 22.3 Pediatri
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22 Privacy Issues 307 patient must
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22 Privacy Issues 309 and receipt o
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Chapter 23 Electronic Mail in Pedia
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23 Electronic Mail in Pediatric Pra
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Chapter 24 Information Management b
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24 Information Management by Patien
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Chapter 25 Overview of Pediatric In
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25 Overview of Pediatric Inpatient
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Chapter 26 Prescribing/Ordering: Co
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26 Prescribing/Ordering: Computeriz
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346 S.H. Mitchell et al. 27.2.1 Med
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348 S.H. Mitchell et al. context of
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350 S.H. Mitchell et al. 27.3.3.1 C
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352 S.H. Mitchell et al. challenges
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354 S.H. Mitchell et al. work round
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Chapter 28 Medication Administratio
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28 Medication Administration and In
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Chapter 29 Understanding and Preven
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29 Understanding and Preventing Err
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29 Understanding and Preventing Err
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