Health Information Management Technology

Health Information Management Technology

Health Information Management Technology

Assignment: Answer Real world cases 5.1 and 5.2 questions; at least one page for each real world case; cite textbook. Please see chapter readings from textbook below


Real-World Case 5.1

The 2015 Edition EHR technology certification criteria state the following:

Smoking status: Enable a user to electronically record, change, and access the smoking status of a patient in accordance with the standard specified.

· 45 CFR 170.315(a)(11). Coded to one of the following SNOMED CT codes:

· Current everyday smoker. 449868002

· Current some day smoker. 428041000124106

· Former smoker. 8517006

· Never smoker. 266919005

· Smoker, current status unknown. 77176002

· Unknown if ever smoked. 266927001

· Heavy tobacco smoker. 428071000124103

· Light tobacco smoker. 428061000124105


Objective: Record smoking status for patients 13 years or older.

Measure: More than 85 percent of all unique patients 13 years old or older seen by the eligible professional or admitted to the eligible hospital’s or critical care hospital’s inpatient or emergency department during the EHR reporting period have smoking status records as structured data.

A quick reference for meeting the smoking status promoting interoperability requirement is ­included in the American Academy of Family Physicians (AAFP) Tobacco and Nicotine Cessation Toolkit. The AAFP supports the incorporation of tobacco cessation into EHR templates (AAFP 2015). The quick reference provides guidance on what should be included in a tobacco cessation EHR template.


Real World Case 5.1


1. Why would SNOMED CT be used to record the smoking status of a patient on an EHR template?

2. Why was ICD-10-CM not chosen as the system to capture smoking status?

3. Review the SNOMED CT codes. Which ones have a namespace identifier and an extension? What part of the identifier is the namespace and what part is the extension?



Real-World Case 5.2

Opioid use is a major concern for healthcare professionals and organizations worldwide. Even governmental agencies are becoming involved. For example, the National Institutes of Health launched the Helping to End Addiction Long-term as a way to speed scientific solutions to curtail the national opioid public health crisis. The accurate identification of opioid use disorder is important to the success of the research that will take place. DSM-5, ICD-10-CM, SNOMED CT, and in the future ICD-11-MMS are all possible ways to identify cases for research.


Real World Case 5.2


1.            Why would DSM-5, ICD-10-CM, SNOMED CT, and ICD-11-MMS be used to record opioid use disorder?



2.             If you were helping with a research study on opioid use disorder and asked to identify what should be included from SNOMED CT, ICD-10-CM, and ICD-11-MMS for opioid use disorder, what would your report say?


Websites may be used to look up opioid use disorder:






3.             Considering the same research study, what would you point out as changes in the classification for opioid use disorder between ICD-10-CM and ICD-11-MMS?











Health Information Management Technology,

An Applied Approach

Nanette Sayles, Leslie Gordon


Copyright ©2020 by the American Health Information Management Association. All rights reserved.

Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced,

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recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue,

21st Floor, Chicago, Illinois 60601-5809 (


ISBN: 978-1-58426-720-1

AHIMA Product No.: AB103118











Clinical Terminologies, Classifications, and Code Systems

Health information management (HIM) professionals play a crucial role in capturing and organizing clinical data. With the adoption of electronic health records (EHRs), organizing clinical data may involve several labels. For example, the Office of the National Coordinator for Health Information Technology (ONC) uses vocabulary (a list of collection of clinical words or phrases with their meanings), terminology, or code set to describe standards to support interoperability (ONC 2018a). Vocabulary is a list or collection of clinical words or phrases with their meanings. Standards organizations may also use the label nomenclature (a recognized system of terms that follows pre-established naming conventions), classification (a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings), or code system (an accumulation of terms and codes for exchanging or storing information). See table 5.1 for general definitions of each label. Nomenclature is a recognized system of terms that follows pre-established naming conventions. Classification is a clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings and facilitates mapping standardized terms to broader classifications or administrative, regulatory, oversight, and fiscal requirements. A code is an identifier of data. A code set is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic or procedure codes, and includes the descriptors of the codes. A code system is the accumulation of terms and codes for the exchange or storing of information.

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