Data and Terminology Standardization

 

The Veterans Health Administration (VHA) Data and Terminology Standardization Office examines the way the mobile application (App) presents data to the patient to ensure that the definitions and clinical terms conform to the national health industry standards the VA follows. We guard against ambiguous terms and measures, and against collecting data that cannot be understood and correctly interpreted in VA records.

We evaluate the App according to the types of data it handles. For example, if your App cites immunizations, we ensure the App follows the Center of Disease Control's National Center of Immunization and Respiratory Diseases Vaccine Administered (CVX) code. As early as possible, you would provide us with a list of immunization data handled by your App. We would map (match to a code) these immunizations to the corresponding CVX codes.

There are other standards besides elements like immunizations. For example, if your App references a pain scale, we make sure the scale is accurate and verifiable, and that it does not violate existing pain-scale guidelines.

Our office follows the VA/DoD Target Health Standards Profile (HSP) for terminology standards. The DoD and the VA Health Architecture Review Board (HARB) in support of the DoD/VA Joint Executive Council (JEC) Joint Strategic Plan (JSP) have approved the HSP. You can view the HSP here: https://www.voa.va.gov/DocumentView.aspx?DocumentID=1089.

JEC and Strategic Council http://www1.va.gov/op3/docs/StrategicPlanning/VA_DoD_JEC_JSP_FY_2013_2015.pdf

This profile includes standards established under the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Records Final Rule (28 July 2010) for Meaningful Use, eHealth Exchange [formerly the Nationwide Health Information Network (NwHIN)], the DoD Information Technology Standards Registry (DISR), and the VA Technical Reference Model (TRM). The HSP also reflects technical and data standards in support of the Virtual Lifetime Electronic Record (VLER) and the Integrated Electronic Healthcare Record (iEHR) initiatives.

The review will also follow Health Level 7 (HL7) Standards. HL7 recommends that different standards be used for specific elements (i.e., SNOMED for clinical terms, LOINC for laboratory terms, and Rx Norm for pharmacy terms). Upon the submission of the spreadsheet, the certifier will find and interpret the values or “mapping” of the terms with standardized terms.

References

These references are current as of November 21, 2013. Note: Some versions are not finalized.

C83

http://hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=717d69a5-6bc4-4f8b-a22c-197130b50567

C32 2.5 Recognized copy

http://hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=e1b99525-a1a5-48f6-a958-4b2fc6d7a5c7

C80 2.0.1 Review copy

http://hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=1d34ed96-351f-4f00-9a84-3e2da455315e

C154 1.0.1 Review copy

http://hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=57883e35-7ae3-4f3d-b132-c4ec4207a827

C-CDA 2.0 Final Implementation Guide

http://www.hl7.org/documentcenter/public/wg/structure/20111202_Consolidation_Publication_Draft.zip

NIST C32 FAQ (non-normative)

http://healthcare.nist.gov/use_testing/faq.html

CDA Tools (non-normative)

http://www.cdatools.org/infocenter/index.jsp?topic=%2Forg.openhealthtools.mdht.uml.cda.ccd.doc%2Fcontent%2FClinicalStatementTemplates.html

Meaningful Use (Stage 2)http://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2

MU test guide

http://www.healthit.gov/sites/default/files/170.314a11smokingstatus_2014_tp_approvedv1.2.pdf

Blue button C-CDA analysis

http://bluebuttonplus.org/healthrecords.html

Health App Certification Program

http://www.happtique.com/

Food & Drug Admin. App standardshttp://www.fda.gov/medicaldevices/digitalhealth/mobilemedicalapplications/default.htm
Food & Drug Admin. App standardshttp://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM263366.pdf
Veterans Health Information Modelhttp://enterprise.metadata.va.gov/pls/apex/f?p=VHIM:1:3391517879721404
Veterans Health Information Modelhttp://enterprise.metadata.va.gov/pls/apex/f?p=2600:500:0
Health Standards Profilehttps://www.voa.va.gov/DocumentView.aspx?DocumentID=1089. Also, 2013 Target DoD-VA Health Standards Profile - September2012.doc

VA/DoD Joint Execute Council &

Strategic Plan

http://www1.va.gov/op3/docs/StrategicPlanning/VA_DoD_JEC_JSP_FY_2013_2015.pdf

eHealth Exchange

http://www.healthit.gov/providers-professionals/faqs/what-ehealth-exchange

DoD Information Technology Standards

Registry

https://acc.dau.mil/CommunityBrowser.aspx?id=148577
VA Technical Reference Model (TMR)

http://www.va.gov/TRM/TRMHomePage.asp

Vertual Lifetime Electronic Record

(VLER)

http://www.va.gov/vler/

Logical Observation and
Identifiers Numeric Codes (LOINC)

http://loinc.org/

Systematic NoMenclature
of Medicine Clinical Terms
(SNOMED-CT)

http://www.cliniclue.com/cliniclue_xplore

Rx Norm Navigator (RxNav)

http://rxnav.nlm.nih.gov/

Health Level 7 (HL7)www.hl7.org
Centers of Disease Control on vaccineshttp://www.cdc.gov/vaccines/programs/iis/code-sets.html