My name is Robert Lapp. I am the director of dental informatics for the American Dental Association (ADA). It is my pleasure to appear today on behalf of the ADA before the Computer-based Patient Record Work Group (CPRWG) of the National Committee on Vital and Health Statistics (NCVHS). The following points summarize our statement and recommendations as a terminology and code developer for consideration in preparing the report to the Secretary on adoption of uniform data standards for patient medical record information.
The American Dental Association believes that, for optimal patient benefit, with assurance of confidentiality safeguards, appropriate health information should be available at the time and place of care to practitioners authorized by the patient through the development of a computer-based patient health record.
The ADA's Working Group on the computer-based health record found that five fundamental criteria are essential for information to contribute to quality health care outcomes and efficient and economical care delivery:
These characteristics can be summarized in the Working Group's statement:
“Complete and accurate information must be seamlessly available to all users authorized by the individual, in a form optimally useable at the time and place required, across the traditional boundaries of health care profession, specialty or care delivery environment.”
A. Why is comparable PMRI required, what functions does it serve?
The availability of comparable health information at the point of decision enables the patient, care giver and manager to efficiently use automation to enhance their best judgement in achieving long sought optimal quality and economy in care delivery.
B. How comparable does the PMRI need to be for these purposes, i.e., how precise, how accurate? What are the consequences if the PMRI is not accurate?
Lack of comparability, precision and accuracy reduces the quality of care delivery to sub-optimal levels and increases its cost by the conversion, verification and interpretation expense.
A. What is the intended purpose of your medical terminology? What is it currently used for?
B. What is the clinical domain, scope, or healthcare setting addressed by your medical terminology?
To achieve uniformity, consistency and specificity in accurately reporting dental treatment, the ADA developed the Code on Dental Procedures and Nomenclature (Dental Code). The Dental Code, as published in the ADA's Current Dental Terminology (CDT), is intended to be used by dental professionals to record and report care provided to patients. It is also used by third-party payers for reimbursement.
C. What evidence do you have of market acceptance of your terminology? {Ask users what their perceptions of gaps are}
The Dental Code is used by all practicing dentists in the United States to record and report dental treatment and procedures. This includes clinical, academic and administrative settings. The Dental Code has also been proposed as the HIPAA standard dental code.
During the preparation of the third edition, members of the ADA's Council on Dental Benefit Programs, representatives of the ADA recognized dental specialties, representatives of the Health Care Financing Administration and representatives from nationally recognized payer organizations participated in the revision process. This revision process provides the opportunity to resolve any user reported gaps in the terminology.
D. In what areas are you now planning to expand your terminologies?
The ADA's Systematized Nomenclature of Dentistry (SNODENT) will provide dentistry with a comprehensive terminology to establish and define dental and oral disease classifications and co-morbidities. SNODENT was developed and is maintained by the American Dental Association. SNODENT will be an integral part of the computer-based patient record and, therefore, will be composed of diagnoses, signs, symptoms and complaints. This provides the means not only for diagnostic coding, but when collected compiled and analyzed, reliable diagnostic treatment outcomes data can be compiled. It is may also used by third-party payers to eliminate the need for narrative descriptions and other attachments. Dental practice management systems vendors are expected to incorporate SNODENT in their systems to maintain a comprehensive patient health record.
The ADA’s new coding system, SNODENT, is a micro-glossary of the Systematized Nomenclature of Medicine (SNOMED) and will be contained in SNOMED Version 3.6 which is maintained by the College of American Pathologists (CAP). The ADA has a licensing agreement with CAP for this purpose. The Dental Code is the established and accepted standard for dental procedures.
A. Which message format standards reference or include your medical terminology?
B. Is the use of your medical terminology within these message format standards required, preferred, or optional?
The ADA is a designated code source and the Dental Code is used in the X 12 message format and has been proposed as the required HIPAA standard dental procedure code. We hope SNODENT will also be accepted in the X 12 standard and named as the preferred HIPAA standard dental terminology.
Although both the ADA's dental procedure codes and SNODENT could be used in other message format standards, such as HL-7 and LOINC, these formats are not currently used in dentistry. If a patient health record design is adopted using these or other message formats, we would advocate acceptance of both SNODENT and the dental procedure codes as the required terminology for dentistry.
The ADA is also actively participating in the ISO TC 215 Working Group 3 on health concept representation to ensure that international terminology standards are adopted that provide comparable health record information.
A. What are they?
B. What can be done to address these issues in a one-to four-year time frame?, a five- to ten-year time frame?
The designation of HIPAA standard terminologies is a major step that will promote convergence toward comparable nomenclature for health records. The health record is essentially the repository of transactions, so an electronic transaction terminology standard will improve the consistency of the patient record over time.
It must be recognized that terminologies are dynamic and change to reflect technological and methodological advances. Consequently, government adoption or endorsement of terminologies must not allow stagnation. Rather than standardize a specific terminology version, the ADA would urge the designation of terminology sources. In addition, it is important to encourage those with coding requirements to work with existing terminology sources to minimize duplicate efforts. This will ensure that consistent terminologies evolve to meet the changing needs of health care and provide comparable information in the health record for both immediate and future use.
A. If so, what should be the role of the government?
Continued participation of government agencies in the national and international standards development processes will promote the comparability of patient health record information. As previously stated, the HIPAA standard terminologies and code sets for transactions will encourage comparable nomenclature for health records.
Specifically, the efforts of the ISO TC 215 Working Group 1 that is developing an international model of the health record should be supported. Increasingly, the health record format transcends national boundaries for both patients, health professionals and vendors. Comparability of both content, terminology and format are essential for general acceptance.
B. Is there a need for increased coordination among terminology developers? If so what type.
C. Is there a need to coordination between terminology developers and message standard developers? What type or form should it take?
D. In the short run (1-4 years)/long run (5-10 years)?
Coordination and communication as proposed in the HIPAA regulations for designated code sources and content committees will ensure that terminology standards are maintained. Formal coordination through the National Uniform Data Committee (NUDC) can provide the necessary coordination.
We thank you for the opportunity to address this important Work Group and look forward to providing further assistance in our roles of HIPAA consultant, an ANSI standards development organization and the representative of organized dentistry.