Embracing the International
Agenda... Nutrition care processes,
outcomes and standardised
terminology
Introduction to Coding, Classifications
and Terminologies
Ingrid Darnley
BDA Policy officer Clinical Quality
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
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.
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.
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.
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.
Characteristics of Snomed CT (terminology)
vs ICD-10 and OPCS (classifications)
Together, terminologies, such as SNOMED-CT, and classification systems, such as ICD10 and ICD-10, complement each other and provide the common clinical language
necessary for interoperability and the effective sharing of clinical data.
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.
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
http://members.bda.uk.com/profdev/profpractice/modeldieteticpractice/MPNDPintro.pdf
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)
http://members.bda.uk.com/profdev/profpractice/mo
deldieteticpractice/BDA_BriefingRecordStandards.pdf
outlines the links between the Process, IDNT and the
development of records (including electronic) and
standards for records
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.
And for more information …..
The next two speakers……………………….
http://www.connectingforhealth.nhs.uk/
Information Services Division (NHS Scotland) :Terminology Services
and Clinical Coding
http://www.isdscotland.org/Products-and-Services/TerminologyServices/Coding-and-Terminology-Systems/
Academy of Nutrition and Dietetics http://www.eatright.org/
BDA Informatics and record standards work stream
Sue Kellie [email protected] and Ingrid Darnley at [email protected]