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HIM 112L Snomed
Electronic Health Records Software Application (Hagerstown Community College)
Studocu is not sponsored or endorsed by any college or university
HIM 112L Snomed
Electronic Health Records Software Application (Hagerstown Community College)
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Knowledge Activity: SNOMED CT (Associate)
Student instructions
1.
If you have questons about this actvity, please contact your instructor for assistance.
2.
You will review the chart of
Melinda Goble
to complete this actvity. Your instructor has
provided you with a link to the
SNOMED CT (AS)
actvity. Click on
2: Launch EHR
to
review the patent chart and begin this actvity.
3.
Refer to the patent chart and any suggested resources to complete this actvity.
4.
Document your answers directly on this actvity document as you complete the actvity.
When you are fnished, you will save this actvity document to your device and upload
this actvity document with your answers to your Learning Management System (LMS).
Background
SNOMED CT, or the Systemized Nomenclature of Medicine Clinical Terms, is a clinical
terminology set used to record patent data to facilitate decision-making and analytcs. It strives
to be the global standard and has over 30 contributng member countries working to create a
common language to exchange health informaton clearly and accurately. SNOMED CT is specifc
and comprehensive, currently containing more than 300,000 medical concepts, divided into
hierarchies.[ CITATION SNO18 \l 1033 ]
Each concept is represented by an individual number and several concepts can be used
simultaneously to describe a complex conditon. By using numbers to represent medical
concepts, SNOMED CT provides a standard by which medical conditons and symptoms can be
referred to internatonally. SNOMED CT is designed to be managed by a computer. It's not just a
fat list of numbers and corresponding terms. It's a complex relatonship of concepts. These
concepts are shown in the image below.
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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Image from Snow Owl User Guide [ CITATION Sno18 \l 1033 ]
SNOMED CT maps to other internatonal standards such as ICD-10. If SNOMED is not
implemented in the EHR, an online mapping tool can be used. You’ll be exploring the use of I-
MAGIC as part of this actvity, and many other optons exist.
SNOMED CT vs. ICD
SNOMED CT is diferent from ICD-10.
SNOMED CT is clinical terminology designed for direct use by healthcare providers
during the process of providing care. It is designed for input of problems, encounter
diagnosis, procedures, health history, and smoking status. SNOMED CT is more granular
and includes more than 300,000 concepts, 790,000 descriptons, 19 hierarchies, and
920,000 relatonships.
ICD codes, on the other hand, are designed to be used by coding professionals once the
episode of care (the encounter) is completed. The code captures the diagnosis or
problem. ICD codes are designed for output and billing. ICD-10 currently includes more
than 150,000 codes. [ CITATION Hel13 \l 1033 ]
SNOMED CT and Electronic Health Records
When talking about SNOMED CT in terms of use with an Electronic Health Record (EHR),
SNOMED CT improves communicaton and increases the availability of health informaton. If
clinical informaton is stored in the EHR in ways that allow consistent, meaning-based retrieval
(structured data entry), the benefts are greatly increased. The added benefts range from
increased opportunites for real-tme decision support to more accurate retrospectve reportng
for research and management.
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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Visit the SNOMED Internatonal website to understand the benefts to individuals, populatons,
and health care decisions:
htps://www.snomed.org/snomed-ct/why-should-i-get-snomed-ct
.
SNOMED CT and Requirements
As part of Meaningful Use Stage 2, 2014 EHR certfcaton criteria designates the use of
SNOMED CT for problems. This came at a similar tme when facilites were to update from using
ICD-9 to ICD-10. Mapping programs from one classifcaton system to another were developed
to assist with the transiton. [ CITATION Hel13 \l 1033 ]
Mapping
Implementaton of SNOMED CT can help providers with the transiton to ICD-10 because
computer systems can use SNOMED CT content to seamlessly generate ICD-10 codes. Computer
systems designed for this purpose use a mapping system to suggest recommended ICD-10 codes
based on SNOMED CT codes and, if applicable, additonal informaton obtained from the
electronic patent record or from direct user input. The healthcare provider or professional
coder should then review the recommended ICD-10 codes for accuracy.
Clinical informaton recorded using SNOMED CT may include data that is relevant to reports,
statstcal returns, billing claims, etc. that need to be encoded using a specifc code system or a
statstcal classifcaton such as ICD-10.
A simplifed example of mapping:
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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The following is a screen shot of how a provider documents a patent’s problems in the EHR at
an Indian Health Services (IHS) facility. In this example, the provider selects the SNOMED CT
term that best fts the patent’s conditon (the input) with the EHR having automatcally mapped
it to the appropriate ICD-10 code. Then the ICD-10 code is used for billing purposes (the
output).
The activity
SNOMED CT is not incorporated into EHR Go. You’ll be using an external program to explore
SNOMED with the EHR Go health record and mapping with ICD-10.
1.
In EHR Go, select Step 2: Launch EHR. Select
New Session
to open the chart for Melinda
Goble.
2.
Go to the Problems tab. Melinda has four problems identfed in her chart. However,
they do not have specifc codes assigned. Use the EHR to identfy the corresponding ICD-
10 codes. You may also use other resources such as textbooks and online websites.
a.
To use the EHR, select
New
when on the Problems tab.
b.
Type in the name of the problem in the Problem feld. A list of the possible ICD-
10 codes will appear. Choose the code/descripton that is most accurate. Fill the
answer in the table below.
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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c.
Repeat for the additonal problems. There’s no need to save the problems in the
chart - you’re just using it to look up the ICD-10 codes.
3.
Use the I-MAGIC interactve program from the Natonal Insttutes of Health, Department
of Health and Human Services, to determine the SNOMED code. I-MAGIC is a free,
simple, online, interactve program that will assist in mapping with ICD-10. Copy and
paste the following link into your internet browser to launch I-MAGIC:
htps://imagic.nlm.nih.gov/imagic/code/map
a.
Enter the ICD-10 problem name (not code) in the Problem feld
b.
A dropdown list of SNOMED problems will appear. Select the one that most
closely refects the ICD-10 code.
c.
Then select
Get ICD Codes
. Ensure the resultng ICD-10 code generated for the
SNOMED problem matches what you determined in Step 2 above. If so, fll in the
SNOMED code in the table below.
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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Questions
1.
Complete the following table by entering the problem’s found in Melinda’s chart and the
corresponding ICD-10 and SNOMED names and codes. Refer to the steps in the above
Actvity secton to do so.
Problem Name
Problem Name & ICD-10 code
SNOMED CT Name & Code
Right Shoulder Pain
Pain in right shoulder – M25.511
Pain of right shoulder joint
(15917011000119100)
Obesity
Obesity, unspecifed – E66.9
Obesity (414916001)
Hypertension
Essental Hypertension – I10
Essental
Hypertension
(59621000)
Diabetes Mellitus Type
2 or unspecifed
Type 2 Diabetes Mellitus with
Unspecifed Complicaton – E11.8
Diabetes Mellitus type 2 -
44054006
2.
What is SNOMED CT used for?
SNOMED CT is used as a clinical terminology set that is
used to record patent data
3.
How is SNOMED CT diferent than ICD-10? Which is more robust?
SNOMED CT is a
clinical terminology set that is used by providers during the process of providing care. It
is used for input of problems, encounter diagnosis, procedures, health history, etc. ICD-
10 is used once care is completed and is used for billing and captures the diagnosis and
problems. The SNOMED CT is more robust.
4.
Are there advantages to implementng both SNOMED CT and ICD-10 in the EHR?
a.
Yes, there are advantages to using both. SNOMED CT lays a foundaton for
improving the quality of the clinical informaton captured in the EHR.
5.
Are there disadvantages to using both?
a.
Yes, there is a disadvantage to using both SNOMED CT and ICD-10.
6.
Is the use of SNOMED CT currently required by hospitals and clinics in the US?
a.
yes
Submit your work
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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Document your answers directly on this actvity document as you complete the actvity. When
you are fnished, save this actvity document to your device and upload this actvity document
with your answers to your Learning Management System (LMS). If you have any questons about
submitng your work to your LMS, please contact your instructor.
Learning objectives
1.
Describe components of revenue cycle management and clinical documentaton
improvement (2)
2.
Evaluate revenue cycle processes (5)
References
Helwig, Amy.
HealthITBuzz
. 29 October 2013. 31 May 2018. <htps://www.healthit.gov/buzz-
blog/electronic-health-and-medical-records/ehr-certfcaton-criteria-snomed-ct-doctors-
transiton-icd10/>.
SNOMED CT
. 31 May 2018. 31 May 2018. <htps://www.snomed.org/about>.
"Snow Owl User Guide." n.d.
htp://b2i.sg/.
31 May 2018.
EHR Go Knowledge Activity: SNOMED CT (Associate) HAK1008.2
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