classification
Health Informatics (HI) is a science
that defines how health information is
technically captured, transmitted and
utilized.
Health informatics focuses on
information systems, informatics
principles, and information technology
as it is applied to the continuum of
healthcare delivery.
Health Informatics (HI) is a science
that defines how health information is
technically captured, transmitted and
utilized.
Health informatics focuses on
information systems, informatics
principles, and information technology
as it is applied to the continuum of
healthcare delivery.
It is an integrated discipline with specialty
domains that include management science,
management engineering principles,
healthcare delivery and public health,
patient safety, information science and
computer technology.
Health Informatics programs demonstrate
uniqueness by offering varied options for
practice or research focus.
There are four major focus research areas in informatics education
reflecting various disciplines:
Medical/Bio Informatics – physician and
research based, attracts medical students
 Nursing Informatics – clinical and research
based, attracts nursing students
 Public Health Informatics – public health
and biosurveillance based, attracts public health
students
 Applied Informatics – addresses the flow of
medical information in an electronic environment
and covers process, policy and technological
solutions, attracts HIM students

The terms medical record, health record, and
medical chart are used somewhat interchangeably
to describe the systematic documentation of a
single patient's medical history and care across
time within one particular health care provider's
jurisdiction.
The medical record includes a variety of types of
"notes" entered over time by health care
professionals, recording observations and
administration of drugs and therapies, orders for
the administration of drugs and therapies, test
results, x-rays, reports, etc.
The terms are used for both the physical folder
that exists for each individual patient and for the
body of information found therein.
Medical records have traditionally been compiled
and maintained by health care providers, but
advances in online data storage have led to the
development of personal health records (PHR)
that are maintained by patients themselves, often
on third-party websites.
Because many consider the information in
medical records to be sensitive personal
information covered by expectations of privacy,
many ethical and legal issues are implicated in
their maintenance, such as third-party access and
appropriate storage and disposal.
Although the storage equipment for medical
records generally is the property of the health care
provider, the actual record is considered in most
jurisdictions to be the property of the patient, who
may obtain copies upon request.
Purpose
 The information contained in the medical record
allows health care providers to determine the
patient's medical history and provide informed care.
 The medical record serves as the central repository
for planning patient care and documenting
communication among patient and health care
provider and professionals contributing to the
patient's care.
 An increasing purpose of the medical record is to
ensure documentation of compliance with
institutional, professional or governmental
regulation.
Contents
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Medical history
Surgical history
Medications and medical allergies
Family history
Social history
Habits
Growth chart and developmental history
Assessment and plan
Orders and prescriptions
Progress notes
Test results….. Etc..
Contents
 Ownership of patient's record
 Accessibility
 Destruction
 In general, entities in possession of
medical records are required to maintain
those records for a given period.
 In the United Kingdom, medical records
are required for the lifetime of a patient
and legally for as long as that complaint
action can be brought.
Contents
 Generally in the UK, any recorded information
should be kept legally for 7 years, but for
medical records additional time must be
allowed for any child to reach the age of
responsibility (20 years).
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 Medical records are required many years after a
patient’s death to investigate illnesses within a
community (e.g., industrial or environmental
disease or even deaths at the hands of doctors
committing murders, as in the Harold Shipman
case).
Abuses, Breaches & Privacy
 The outsourcing of medical record transcription and
storage has the potential to violate patient-physician
confidentiality by possibly allowing unaccountable
persons access to patient data.
 Falsification of a medical record by a medical
professional is a felony in most United States
jurisdictions.
 Governments have often refused to disclose medical
records of military personnel who have been used as
experimental subjects.
Data Breach
 Given the series of medical data breaches and the lack
of public trust, some countries have enacted laws
requiring safeguards to be put in place to protect the
security and confidentiality of medical information as
it is shared electronically and to give patients some
important rights to monitor their medical records and
receive notification for loss and unauthorized
acquisition of health information.
 The United States and the EU have imposed
mandatory medical data breach notifications.
Privacy
 The federal Health Insurance Portability and
Accessibility Act (HIPAA) addresses the issue of
privacy by providing medical information handling
guidelines. (US)
Classification of Healthcare Records
 Medical classification, or
 medical coding,
 is the process of transforming
descriptions of medical diagnoses and
procedures into universal medical
code numbers.
medical
diagnoses
medical
procedures
universal
medical
code
numbers
Classification of Healthcare Records
 Medical classification, or medical coding, is the
process of transforming descriptions of medical
diagnoses and procedures into universal medical
code numbers.
 The diagnoses and procedures are usually taken
from a variety of sources within the health care
record, such as the transcription of the physician's
notes, laboratory results, radiologic results, and
other sources.
Medical classification systems are used for a
variety of applications in medicine, public
health and medical informatics, including:
statistical analysis of diseases and
therapeutic actions
reimbursement; e.g., based on diagnosisrelated groups
knowledge-based and decision support
systems
direct surveillance of epidemic or
pandemic outbreaks
There are country specific standards and
international classification systems.
Classification Types
Types of coding systems specific to health care include:
Diagnostic codes
Are used to determine diseases, disorders, and symptoms
Can be used to measure morbidity and mortality
Examples: ICD-9-CM, ICD-10
Procedural codes
They are numbers or alphanumeric codes used to identify
specific health interventions taken by medical professionals.
Examples: ICPM, ICHI
Pharmaceutical codes
Are used to identify medications
Examples: AT, NDC
Topographical codes
Are codes that indicate a specific location in the body
Examples :ICD-O, SNOMED
SNOMED
The Systematized Nomenclature of Medicine
(SNOMED) is the most widely recognised
nomenclature in healthcare.
Its current version, SNOMED Clinical Terms
(SNOMED CT), is intended to provide a set of concepts
and relationships that offers a common reference point
for comparison and aggregation of data about the
health care process.
SNOMED CT is often described as a reference
terminology.
SNOMED
SNOMED CT contains more than 311,000 active
concepts with unique meanings and formal logic-based
definitions organised into hierarchies.
SNOMED CT can be used by anyone with an Affiliate
License, 40 low income countries defined by the World
Bank or qualifying research, humanitarian and
charitable projects.
SNOMED-CT is designed to be managed by
computer, and it is a complex relationship concepts.
SNOMED
SNOMED CT and ICD are designed for different
purposes and each should be used for the purposes for
which they were designed.
As a core terminology for the EHR, SNOMED CT
provides a common language that enables a consistent
language that enables a consistent way of capturing,
sharing, and aggregating health data across specialties
and sites of care.
SNOMED
SNOMED CT is used directly by healthcare providers
during the process of care, whereas ICD is used by
coding professionals after the episode of care.
SNOMED CT
SNOMED Clinical Terms is a systematically organized
computer processable collection of medical terms
providing codes, terms, synonyms and definitions used
in clinical documentation and reporting.
SNOMED CT (Systematized Nomenclature of
Medicine -- Clinical Terms) is a standardized,
multilingual vocabulary of clinical terminology that is
used by physicians and other health care providers for
the electronic exchange of clinical health information.
SNOMED CT
SNOMED CT is considered to be the most
comprehensive, multilingual clinical healthcare
terminology in the world.
SNOMED CT provides the core general terminology
for electronic health records. SNOMED CT
comprehensive coverage includes: clinical findings,
symptoms, diagnoses, procedures, body structures,
organisms and other etiologies, substances,
pharmaceuticals, devices and specimen.
SNOMED CT
SNOMED CT provides for consistent information
interchange and is fundamental to an interoperable
electronic health record.
It allows a consistent way to index, store, retrieve, and
aggregate clinical data across specialties and sites of
care.
It also helps in organizing the content of electronic
health records systems by reducing the variability in the
way data is captured, encoded and used for clinical care
of patients and research.
SNOMED CT
SNOMED CT can be used to record clinical details of
individuals in the electronic patient records.
It also provides the user with a number of linkages to
clinical care pathways, shared care plans and other
knowledge resources, in order to facilitate informed
decision-making and support long term patient care.
The availability of free automatic coding tools and
services, which can return a ranked list of SNOMED CT
descriptors to encode any clinical report, could help
healthcare professionals to navigate the terminology.
SNOMED CT
SNOMED CT is a terminology that can cross-map to
other international standards and classifications.
SNOMED CT is a multinational and multilingual
terminology, which can manage different languages and
dialects.
SNOMED CT is currently available in American
English, British English, Spanish, Danish and Swedish,
with other translations under way or nearly completed
in French and Dutch.