Medical Coding Essay Example

Medical Coding Essay Example Medical Coding Paper Medical Coding Paper To come up with a reliable and proper health information system, we need to understand various sections of the information system that form its underlying pillars. These include: Database characteristics and structure A database is an organization of data in a logical form. â€Å"Data† is a body of fact or figures, which have been collected systematically for one or more specific purposes. It can exist in the forms of linguistic expressions (e. g. name, age, address, date, ownership), symbolic expressions (e. g. traffic signs), mathematical expressions (e.  g. E = mc2) among others. Data is stored in a â€Å"database† which is structured to store various types of information in its different forms (Blair, 1999). Therefore a database can be defined as an automated, formally defined and centrally controlled collection of persistent data used and shared by different users in an enterprise (Date, 1995 and Everest, 1986) Information â€Å"Information† is the data which have been processed into a meaningful form understandable by a recipient and is of perceived value in current or prospective decision making. Data is converted into information through processing like modeling, structuring, conversion and organization. The health facility information system is usually designed to process data by accepting input, processing it and releasing the output in form of information (Cimino, 2006). This information is organized in the information domain. The information system is therefore perceived as being made up of four components: data, technology, process (or application) and people. medical data and information records relevant to the project Some of the information that could be relevant to this project could be Patient name and contacts, medical prescriptions, medical conditions, the patients’ medical history, visiting dates, doctors’ contacts, relevant doctors to various illnesses, doctors’ appointments (Blair, 1999; Health Level Seven, 2008). The importance of uniform terminology, coding and standardization of the data The benefit of using uniform terminology, coding and standardization of the data is hinged in common understanding and interpretation. Uniform coding will ensure that drug administration and medical prescriptions do not conflict rather remain uniform throughout the healthcare facility (Blair, 1999). This therefore requires standardization to ensure that irrespective of the person’s understanding, common meaning is achieved in the health sector. Information standards and organizations that may be applicable, and possibly required To achieve this standardization within a health care facility, there are various information standards and organizations that may be necessary, applicable and possibly required in the project. Such programs include: 1. Unified Medical Language System (UMLS) Metathesaurus developed in 1986. UMLS is useful in developing and distributing multi-purpose electronic Knowledge Sources which is related with lexical programs. Therefore, UMLS use in the project shall enhance system applicability on patient data and decision support (Cimino, 2006). 2. HISB (Health Information Standards Board). HISB is a branch of American National Standards Institutes Healthcare Informatics (ANSI), which is a standards Board provides forum for the voluntary coordination of standards of healthcare informatics. 3. Institute of Electrical and Electronics Engineers, Inc (IEEE), which sets standards for computers. 4. The IOM Committee on Patient Safety Data Standards, a group within the Institute of Medicine that has the charge of producing a detailed plan to facilitate the development of data standards applicable to the collection, coding, and classification of patient safety information (Szolovits, 2003). 5. International Classification of Diseases (ICD-9CM) Clinical Modification, which provide a way to classify morbidity data for indexing of medical records, medical case reviews, and ambulatory and other medical care programs (Szolovits, 2003). 6. Digital Imaging and Communications in Medicine (DICOM), developed for the transmission of images used internationally for Picture Archiving (Szolovits, 2003). References Blair, J. S. (1999). An Overview of Healthcare Information Standards: IBM Healthcare Solutions. Retrieved July 23, 2008 from http://lists. essential. org/med-privacy/msg00186. html Cimino JJ. (2006), Twenty-First Century Desiderata for Controlled Medical Vocabularies: Methods of Information in Medicine 5, p. 218-231 Health Level Seven: Links to Standards Developers. Retrieved July 23, 2008 from hl7. org/standards/developer. htm Szolovits, P. (2003). Nature of Medical Data: MIT, Intro to Medical Informatics: Retrieved on July 23, 2008 from http://groups. csail. mit. edu/medg/courses/6872/2003/slides/lecture2-prin t. pdf